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A MANUAL OF NURSING. 



FOR NURSES. 



12 5 000 MEDICAL WORDS 

Pronounced and Defined. 

A Pronouncing Medical Lexicon. Containing all the 
Words, their Definition and Pronunciation, that the Student 
generally comes in contact with ; also elaborate Tables of the 
Arteries, Muscles, Nerves, Bacilli, &c. • a Dose List in both 
English and Metric System, arranged in a most convenient form 
for reference and memorizing. Thin 64mo. Gilt Edges. 

Flexible Morocco, $1.00 ; Thumb Index, S1.25. 

The great success of Dr Gould's " New Medical Dictionary " 
suggested the publication of this smaller volume for the pocket. 
It has been prepared upon the same practical, systematic plan as 
the larger book, and, like it, has been based upon the most recent 
medical literature. It contains about 12,000 words — nearly 
double the number in any other pocket medical 
dictionary — many of which words are not to be found in any 
other dictionary, large or small. 

The form and size of the volume (6 x 3f inches) have been 
selected as most practical. It is printed on very good, thin 
opaque paper, from a clear, new type, it is no wider than the 
old-shaped books ; it is thinner ; and the length of the page has 
permitted the addition of several thousand words. It will be 
found to slip readily into any pocket that will take the " 32mos," 
and, unlike them, will not feel or look bulky. 

The tables will be found of great value, as much of the material 
thus classified is not obtainable by English readers in any other 
work. 

Catalogues of Books for Nurses free upon application. 



P. BLAKISTON, SON, & CO., PHILADELPHIA. 



MANUAL OF NURSING: 



MEDICAL AND SURGICAL. 



"" Cursing 

LAURENCE HUMPHRY, M.A., M.D., 



ASSISTANT-PHYSICIAN, AND FORMERLY LECTURER TO PROBATIONER- 
AT ADDEN'BKOOKE's HOSPITAL, CaALBRIDGE 



WITH NUMEROUS ILLUSTRATIONS. 



FIFTEENTH EDITION 



PHILADELPHIA 

P. BLAKISTOX, SOX, & COMPANY, 

1012 WALNUT STREET. 

1896. 



8EP 2? 



PREFACE. 



The following pages are based upon lectures given by me to 
the Probationers at Addenbrooke's Hospital during the last two 
years. The plan adopted is to give a short account of the anatomy 
of each set of organs, and immediately afterwards to treat of the 
diseases of those organs and the appropriate nursing. A descrip- 
tion of Baths, Enemata, Poultices, Bandaging, and various 
Nursing Appliances will be found in the final chapters. An 
Appendix contains receipts of food suitable for Invalids. 

The Symptoms and Management of common Diseases and the 
Complications likely to occur are described in order to assist the 
Nurse in following the course of the malady, the treatment of 
which is assumed to be in the hands of a Medical attendant. 

I am indebted to Sir Dyce Duckworth for the use of his notes 
of Lectures to the Probationers at St Bartholomew's Hospital, 
and to Mr Croft of St Thomas's Hospital for valuable hints on 
nursing in Surgical cases. The Chapter on the Management of 
Childbed contains many of the rules and directions drawn up for 
the Nurses at the General Lying-in Hospital, York Pioad. 

In addition to Illustrations prepared expressly for the work, 
permission has kindly been given me to utilise some of the wood- 
cuts from Messrs Caird and Cathcart's Surgical Handbook, and Dr 

Thomson's Dictionary of Domestic Medicine. 

K H. 



Cambridge, 

November, 1889. 



PREFACE TO THE NINTH EDITION. 



In preparing the Ninth Edition of the " Manual of Nursing " 
a slight revision has been necessary, and some new material 
has been added, comprising, amongst other articles, one on the 
Precautions to be observed and the Measures to be taken when 
an epidemic of Cholera is impending, another on Epidemic 
Influenza, and fuller instructions in Antiseptics and the Anti- 
septic Treatment of Wounds. 

I am much gratified at the favourable way in which the book 
has been received by those engaged in Nursing, and I trust that 
the Additions now made will tend to increase its usefulness. 



LAURENCE HUMPHRY. 



Cambridge, 

February, 1893. 



LIST OF CONTENTS. 



CHAPTER I. 

PAGE 

The General Management of the Sick-Room in Private Houses, 1 

The Sick-Room: — Temperature — Ventilation — Nurse's Dress — Fur- 
niture — Flowers — Carpets — Bed and Bedding — Water-Beds — 
Cleanliness — Quiet. Attendance on Patient : — Washing and Per- 
sonal Care — Bed-Sores — Changing Sheets — Draw-Sheet — Lifting 
and Moving the Patient — Bed-Pans —Inspection of Excreta — 
Feeding-Cups — Medicine Glass — Hot- Water Bottles — Bed-Rest. 
Observation of the Sick : — General Suggestions — Administration 
of Food, Stimulants, and Medicine — Arrangement of Room for 
Operations. 

CHAPTER II. 
General Plan of the Human Body, . . . .14 

Anatomy :— Skeleton — Skull — Spine — Vertebrce — Thorax — Ribs — 
Sternum — Clavicle — Scapula — Humerus — Radius — Ulna — 
Carpus — Metacarpus — Phalanges — Pelvis — Femur — Patella — 
Tibia — Fibula — Tarsus — Joints — Muscles — Fat — Internal 
Organs — Nervous System — Respiratory System — Circulatory 
System — Digestive System — Excretory System — Work and 
Waste — Blood — Capillaries — Clotting — Blood Serum — Excretion 
— Temperature of Body. 

CHAPTER III. 
Diseases of the Nervous System, . . , . .32 

The Nervous System : — Brain — Spinal Cord — Membranea-— Nerves 
— Motion — Sensation — Paralysis — Loss of Sensation — Reflex 
Action. 

Symptoms and Management of Brain Paralysis — Coma— Spinal 
Paralysis — Bed-Sores — Nerve Paralysis — Infantile Paralysis — 
Locomotor Ataxy — Meningitis — Cerebral Tumours — Epilepsy — 
St Vitus's Dance — Hysteria — Delirium — Delirium Tremens — 
Insanitv. 



Vlll LIST OF CONTEXTS. 



CHAPTER IV. 

PAGE 

Diseases of the Respiratory System, . . . .50 

The Respiratory Tract and Respiration — The Lungs — Air-Passages 
Larynx — Trachea — Bronchi — Mechanism of Respiration — The 
Respiratory Act — Importance of Ventilation — Cough and 
Dyspnoea. 

Symptoms and Management of Laryngitis — Bronchitis — Asthma — 
Pneumonia — Pleurisy — Empyema — Pulmonary Consumption — 
Haemoptysis or Spitting of Blood— and other Complications. 



CHAPTER V. 

Diseases of the Heart and Blood-Vessels, . . .68 

Heart, Pericardium — Valves — Aorta — Pulmonary Artery — Sys- 
temic, Portal and Pulmonary Circulations — Movements of Heart 
— Pulse — Dyspnoea — Dropsy — Ascites. 

Symptoms and Management of Pericarditis — Mitral Valve Disease 
— Aortic Valve Disease — Angina Pectoris — Fatty Heart — Con- 
genital Heart Disease— and Aneurysm of Aorta. 

CHAPTER VI. 

Diseases of the Digestive System, . . .80 

The Organs of Digestion — The Mouth — Teeth — Tonsils — Pharynx 
— Epiglottis — Parotid Glands — Gullet — Stomach — Liver and Bile 
— Intestines — Peritoneum — Foods — Digestive Processes — Lym- 
phatics—Indigestion — Vomiting — Haematemesis — Jaundice. 
Symptoms and Management of Gastric Ulcer — Colic — Gail-Stones — 
Peritonitis — Typhlitis — Intestinal Obstruction — Diarrhoea — 
English Cholera — Examination of the Stools. 

CHAPTER VII. 

Diseases of the Skin and Kidney, . . . .93 

Skin — Structure— Sweat Glands — Sebaceous Glands— Nails and 
Hair — Corns and Warts — Erythema — Nettle-Rash — Petechia? — 
Psoriasis — Pigmentation — Management of Eczema — Herpes or 
Shingles — Nsevus — Pediculi or Lice — Scabies or Itch — Tinea or 
Ringworm — Chloasma. 

Kidney — Structure — Ureters — Bladder — Examination of the Urine 
— Deposits — Suppression of Urine — Symptoms and Management 
of Bright's Disease, Acute and Chronic — Albuminuria— Renal 
Colic— Diabetes— Tests for Sugar— Dietary for the Diabetic- 
Sweaty Feet. 



LIST OF CONTEXTS fx 



CHAPTER VIII. 

PAGE 

On Fevers, ...... . 110 

Fever — Different Forms of Fever — Infectious Fevers — Germs — 
Contagion and Infection — Isolation — Rules for Disinfection — 
Incubation and Invasion Periods. 
Symptoms and Management of Chicken-Pox — Scarlatina — Small- 
Pox — Measles — Typhus — Typhoid Fever and its Complications — 
Diphtheria — Mumps — Cholera — Influenza — Rheumatic Fever — 
Malarial Fevers — Ague, 



CHAPTER IX. 
Disease in Children, . . . . . .135 

Observation of Children — The Cry — Attitude in Bed — Complexion 
— History of Illness — Disorders of Infancy — Wasting — Feeding 
— Artificial Food — Teething — Convulsions. 

Symptoms and Management of Rickets — Laryngismus — Thrush — 
Sore Throat — Gastric Catarrh — Constipation — Obstruction — 
Diarrhoea — Infantile Cholera — Chronic Diarrhoea — Typhoid 
Fever— Worms— Tubercular Meningitis— Water on the Brain. 



CHAPTER X. 
Wounds and their Complications.— Ulcers, Burns, and Scalds, 151 

Incised and Lacerated Wounds — Healing by First Intention, by 
Granulation — Dressings — Scalp and Face Wounds — Cut Throat 
— Haemorrhage : Capillary, Venous, and Arterial — Arrest of 
Bleeding — Inflammation and Abscess — Pus or Matter. 

Symptoms and Management of Cellulitis — Erysipelas — Poisoned 
Wounds — Pyaemia or Blood-Poisoning — Tetanus — Ulcers and 
Ulceration — Burns and Scalds. 

CHAPTER XL 
Fractures, , . . . . . . .165 

Fracture by Direct and Indirect Violence — Simple, Compound, and 
Comminuted Fractures — Signs of Fracture — Union of Bone — 
Setting Fractures — First aid in Fracture. 

Management of Fractured Skull — Concussion and Compression of 
the Brain — Fractured Lower Jaw — Spine — Pelvis — Collar-Bone 
— Splints for Fractured Arm — Colles' Fracture — Thigh-Bone — 
Bones of Leg — Patella — Plaster of Paris Case — Crutches — Com- 
pound Fractures — Sprains and Strains — Dislocation. 

b 



X LIST OF CONTENTS. 

CHAPTER XII. 

PAGE 

Operations and Special Surgical Cases, . . . ,177 

Preparing Patient for Operation — Operation Room and Table — 
Management of Patient after Operation — Haemorrhage after 
Operation. 

Management of Hare-Lip — Cleft Palate — Tracheotomy Cases — 
Gangrene — Amputations — Retention of Urine — Catheters — 
Stone in the Bladder — Lithotrity — Lithotomy — Fistula — Piles- 
Hernia— Strangulated Hernia— Ovariotomy. 

CHAPTER XIII. 
The Management of Child- Bed, . . . . .193 

Before Labour — Lying-in Room — Preparation of the Bed — Precau- 
tions against Infectious Diseases — Indications of Commencing 
Labour — Pains — Stages of Labour — Management of Natural 
Labour — Antiseptic Rules for Monthly Nurses — Management 
after Labour — Lochia — Lactation — Prevention of Puerperal Fever 
— Antiseptic Solutions. 

Management of the Infant — Separation — Washing and Dressing — 
Rashes— Travels-Eyes— Rupture— Snuffles. 

CHAPTER XIV. 

Appliances, • . . . . . . , 204 

Baths : — Vapour Baths — "Wet Pack— Half Pack — Tepid Sponging 
— Enemata, Aperient and Nutrient — Douche — Vaginal Injec- 
tions — Nasal Douche — Ice Bags — Poultices— Mustard Leaves— 
Fomentations and Stupes — Counter-Irritation — Blisters — Leeches 
— Cupping, Wet and Dry — Ointments — Suppositories — Eye- 
Drops— Collyria — Ear-Syringing — Throat Applications — Gargles 
— Sprays— Inhalations— Bronchitis Kettle. 



CHAPTER XV. 

Antiseptic Treatment— Bandaging, . - . . 224 

The Antiseptic Treatment — Method— Importance of Cleanliness 
— The Dressings — The Roller Bandage — Rules for Bandaging — 
Simple Spiral — Reversed Spiral — Figure-of-8 — Spica — Capeline 
— Leg Bandage — Finger Bandage — Stump Bandage — Many- 
Tailed Bandage — T-Bandage — Slings — Pads — Sand-Bags. 



LIST OF CONTEXTS x i 



CHAPTER XVI. 
Artificial Respiration— Application of Electricity — Mass- 

AGE, «..«•••. 233 

Artificial Respiration — Clinical Thermometer — Hypodermic Injec- 
tion — Batteries — Application of Electricity— Massage or Rub- 
bing. 

APPENDIX A. 

Cooking for Invalids, ...... 239 

Gruel — Arrowroot — Toast and "Water — Barley "Water — Imperial 
Drink — Linseed - Tea — Rice Water — Lemonade- -Orangeade — 
Egg-Flip— Liebig's Quick Beef-Tea— Beef-Tea— Fluid Beef- 
Infusion of Raw Meat — Chicken Broth — Mutton Broth — Yeal 
Broth— Meat Panada — Meat Jelly — Peptonised Milk — Peptonised 
Beef-Tea — Tea — Revalenta Arabica — Chicken Cream — Caramel 
Custard — Potato Soup. 



APPENDIX B. 
Ice Poultice, ........ 244 

Index, ......... 245 



A MANUAL OF NURSING. 



CHAPTER I. 

The General Management of the Sick-Room in 
Private Houses. 

The Sick-Room : — Temperature — Ventilation — Nurse's Dress — 
Furniture — Flowers — Carpets — Bed and Bedding — Water-Beds 
— Cleanliness — Quiet. Attendance on Patient:— Washing and 
Personal Care — Bed-Sores— Changing Sheets — Draw-Sheet — 
Lifting and Moving the Patient — Bed -Pans — Inspection of 
Excreta — Feeding-Cups — Medicine Glass— Hot- Water Bottles — 
Bed-Rest. Observation of the Sick : — General Suggestions — 
Administration of Food, Stimulants, and Medicine — Arrange- 
ment of Room for Operations. 

The Sick-Room. 

The selection of the sick-room does not usually devolve upon the 
nurse, but she may have opportunities of giving advice, especially 
as to its arrangement, ventilation, warming, and furniture. 

The ideal sick-room should have a southern aspect, a fair possi- 
bility of sunshine, and should be spacious and lofty, quiet, and 
well-ventilated. If possible, it should be isolated from the rest of 
the house, especially in infectious cases. It is also a great advant- 
age to have a second room opening into it, and a lavatory and 
closet on the same floor. It is needless to say that the drainage 
should be in perfect order. 

"With all such attendant advantages, the nurse experiences little 
difficulty in keeping the sick-room cheerful and healthy. It is, 
however, in small houses and in the dwellings of the poor, where 
the patient inhabits a dark, close, and squalid chamber, that her 
resources are tried to the utmost, and her skill and efficiency are 
put to the severest proof. 

A 



2 A MANUAL OF NURSING. 

Temperature. — A thermometer is the only safe guide as to the 
temperature of the room. It should be hung against the wall near 
the bed, and the record taken at intervals during the day. The 
temperature should be kept as nearly as possible at 60° F., 
and on no account be allowed to descend below 50° ; but it should 
be remembered that infants and old people require more warmth 
than adults. In some laryngeal and pulmonary complaints, again, 
as high a temperature as 70° F. may have to be maintained. 

The moisture of the atmosphere can be regulated to a certain 
extent when desirable by a steam-kettle, or by the evaporation of 
water placed in open dishes. An open fire-place is by far the best 
and healthiest means of warming a room ; stoves are not nearly so 
agreeable, since they never create sufficient ventilation, and have 
a tendency to produce dryness in the air. This may, however, be 
counteracted to a certain extent by placing a dish of water on the 
stove, and allowing it to evaporate. The temperature of the room 
should be carefully ascertained to be sufficiently warm before the 
patient is washed or dressed, or rises to have his bed made, and it is 
advisable to have a flannel dressing-gown ready for these occasions. 

In hot weather there may be difficulty in keeping the room 
sufficiently cool, especially when the sun is shining on it. A dark 
green linen blind, outside shutters, or Venetian blinds are the best 
protection. 

Ventilation. — The purity of the atmosphere in the sick-chamber 
is of the highest importance ; it is secured by ventilation, by which 
means a constant stream of fresh air is admitted to replace the air 
which has been rendered unhealthy by the impurities poured into 
it from many sources. Elsewhere an account will be found of 
the changes which the air undergoes in its passage through the 
lungs, whereby the amount of oxygen is diminished, and the car- 
bonic acid and organic material are increased (see Expired Air). 
In addition to these impurities, there are emanations from the 
surface of the body, and particles of putrefying matter from the 
surface of sores and ulcers, and from the sputum and excreta being 
constantly thrown off. These, together with the dust and impuri- 
ties from the combustion of gas or candles, combine to render the 
air unwholesome and unsuitable for respiration. Where many 
sick people are congregated together, the fouling of the air is 
materially increased, and is at once obvious to any one entering 
the room from the fresh air, if the ventilation is imperfect. This 
is most noticeable in the early morning, especially if the windows 
and doors have been closed during the night, as is often the case 
in cold weather. 

The process of ventilation consists in the removal of the warm 



GENEBAL MANAGEMENT OF THE SICK-ROOM. 3 

foul air, and the introduction of fresh air to supply its place. 
Extraction of the foul air is best accomplished by the chimney 
when there is a fire burning, for nothing ventilates a room so well 
in all respects as an open grate with a fire. A continual diffused 
current of air is produced in the direction of the chimney, and 
fresh air enters from all quarters to take its place, so that the air 
of the room is frequently changed. In large rooms there are 
frequently open gratings or holes near the ceiling, communicating 
with the outside, or with shafts for the extraction of the warm 
foul air which ascends by reason of its warmth. 

The admission of fresh air should be managed as far as possible 
without draughts ; if these cannot be avoided altogether, the bed 
should be placed so as to prevent currents of air from passing over 
the patient. 'When necessary, screens may be arranged round the 
bed. Air should be admitted fresh from the outside. It is useless 
to open the door and allow air to enter from an ill-ventilated 
passage or staircase, containing the foul air of the house. The 
windows are the proper means for obtaining a fresh supply of air, 
and in cold or windy weather, those on the sides away from the 
wind should, of course, be used. Less draught is produced by 
opening a window at the top, but in warm weather it may be 
opened both at the bottom and the top. 

How to Avoid Draughts. — It should be remembered that 
windows opened at the bottom are likely to create a draught on 
a level with the patient, and are, therefore, dangerous unless 
carefully managed. An excellent plan of arranging an open 
window is to open the lower sash a few inches from the bottom, 
and to fasten a wooden board, eight to ten inches deep, across 
the lower opening ; or to fit a piece of wood accurately in, and 
close the opening beneath the sash. The air thus enters at the 
middle, where the raised lower sash overlaps the lower end of the 
upper one, and the current is directed upwards towards the ceiling, 
and is thus gradually diffused through the room without draught. 
When the room does not admit of ventilation by this means, other 
substitutes must be employed. For example, the windows in 
adjoining rooms or passages may be opened and air admitted, or 
the door may be opened and a current of air created by shaking 
a clean towel or sheet about the room. In very cold or windy 
weather, when it is impossible to keep windows always open, the 
room should be aired several times a day; the patient being 
entirely covered up, the window may be thrown open, and, if 
necessary, the door also for a few minutes, until the air has been 
changed and feels fresh. If the patient is able to leave the room, 
advantage should be taken of his absence to have it thoroughly 



4 A MANUAL OF NURSING. 

aired and warmed again before his return. Amongst the poor, 
the nurse will find the greatest objection to having windows open, 
partly from ignorance and partly from dread of draughts, and she 
will have to be on her guard that the windows are not shut 
directly her back is turned. This is especially necessary at night, 
when it is of the utmost importance to keep the air fresh. 

Nurse's Dress. — The uniform should consist of washing 
material of light colour, or of serge, merino, or alpaca, in order 
that it may readily show the dirt. For midwifery or infectious 
cases, a print dress should be worn, being less likely to become 
contaminated with dust and dirt, besides being more easily 
cleansed. It is usual for a nurse to wear a neat cap, apron, and 
cuffs 5 she should also be provided with a pair of quiet shoes with- 
out high heels, and should abjure creaky boots. 

In surgical cases where constant dressing of wounds, or removal 
of offensive discharges is required, linen sleeves, which can be 
drawn off and on, may be used. The nurse should always be 
provided with a good pair of scissors, dressing-forceps, a pin- 
cushion with needles and pins, and a thermometer. 

Furniture. — The ordinary furniture of the room should be of 
a simple kind. Those chairs are best which have a wooden frame- 
work with a cane bottom. Stuffed chairs and sofas with coverings 
of woollen material only retain the dust, and may spread infection. 
A light invalid couch with wheels is useful in convalescence. The 
room should be made cheerful and pleasant to the eye, and ar- 
ranged as little like a bed-room as possible; the pictures and wall- 
paper should be considered in cases where the invalid has to keep 
the room for a great length of time. 

Flowers with bright colours, and devoid of scent or strong 
odour, should be selected, and should always be removed at night. 
Some persons are very sensitive in this respect, and are rendered 
faint by the presence of flowers with a strong scent. 

Carpets should not extend over the whole room, but are useful 
to prevent unnecessary noise; they should be light and easily re- 
moved for cleaning; but India matting, especially in summer, is 
an excellent substitute. It should be remembered that fluffy 
mats and long-haired rugs are most objectionable, and that in 
infectious cases carpeting of all kinds must be excluded. 

Bed and Bedding. — The simplest form of bedstead, such as the 
ordinary narrow iron frame, is convenient; but if of a larger size, 
it has this advantage that the patient can be moved to the other 
side while the bed is being remade. Four-post beds with hanging 
curtains are out of place in the sick-room; if the apartment is 
draughty, the patient may be protected by well-arranged screens. 



GENERAL MANAGEMENT OF THE SICK-ROOM. 5 

The bedstead should not be placed with one side against the 
wall, as the nurse should be able to attend to the patient on either 
side of the bed. The position should be adapted to the situation 
of the windows when possible, so as to avoid light falling on the 
eyes in cases in which this is undesirable ; but yet so as to enable a 
convalescent or chronic invalid to look out of the window, or, if 
preferred, to have the light at the back when reading. 

The mattress may be of thin horse-hair, placed on another of 
similar material, or on a palliasse. A spring-mattress, however, or 
a chain-mail bed is preferable, and forms a clean, cool, com- 
fortable bed. If these are too expensive, some cheaper form, 
such as a wool or flock mattress, will have to be substituted. The 
feather-bed in constant use is hot and unhealthy, and is apt to 
allow the patient to sink into uncomfortable holes. The tinder- 
sheet should be spread smoothly, well stretched and tucked in 
under the mattress ; nothing is so uncomfortable as lying on 
rucks. After food the bed should be carefully freed from 
crumbs ; and several times during the day it should be aired by 
raising the covering twice or thrice, and getting rid of the close 
warm air of the interior of the bed. Comfortable pillows, not 
too soft, may be arranged according to the patient's liking ; 
it should be borne in mind that the back requires support when 
the patient is lying propped up. 

Heavy bed-clothes should be avoided, and if extra warmth is 
required a light quilt or coverlet is the best, eider-down being the 
warmest. Counterpanes are heavy and bad for ventilation. It 
is a luxury to the patient if the room is provided with a second 
bed, into which he can be moved for a change during the day, 
while the other is being aired and remade. 

Water-Beds and Air-Cushions. — In cases of chronic illness, 
when the patient has to be kept constantly in bed, or where bed- 
sores are likely to occur, a water-bed is invaluable. The empty 
water-bed should be first placed on the bedstead or palliasse, 
and water at about 90° F. (or less, according to the time of 
the year) gradually poured into it until it is about half-full or 
rather more ; the rest may be distended with air. A folded 
blanket should be placed over it before the bed is made. The 
water-bed should never be lifted with the water in it, and it 
should always be carefully handled, as it is easily damaged and 
is expensive. Care should be taken before it is placed on the 
bed to see that it does not leak. The water may require chang- 
ing after a time in cold weather. Water-pillows may be filled in 
the same way. 

Air-cushions are not so serviceable, but are less expensive. 



6 A MANUAL OF NURSING. 

Cleanliness. — The room should be dusted, tidied, and cleaned 
every day. The floor should be swept with a hand-brush, damped 
to avoid raising the dust; or old tea-leaves or sawdust may be 
used for the same purpose. The dust should not be allowed to 
accumulate under the bed or in the corners of the room. If the 
room is cleaned every day, there will be less need of scrubbing 
the floor; but in long illness, when this is necessary, it is de- 
sirable to move the patient into another room until the boards 
are dry. 

Quiet. — The nurse, as before stated, should never wear rustling 
dresses or creaking shoes, and should avoid heavy or clumsy 
movements, as all such noises are extremely irksome. In cases 
requiring to be kept especially quiet, there is often difficulty in 
limiting the number of visits from anxious friends and relations ; 
but the nurse should ask for definite guidance on this point from 
the medical attendant, and will then have no difficulty in acting 
on his instructions. 

In making up the fire at night, or when the patient is asleep, a stick 
may be used instead of a poker, and the coals should be arranged 
previously ready for use in paper bags, or be put on gently by 
hand, with a glove kept for the purpose. 

Attendance on Patient 

Washing and Personal Care. — The face and hands should be 
washed night and morning, and if the patient is not well enough 
to take a bath, the whole body should be sponged over with warm 
water and soap once a day (see Tepid Sponging). The teeth should 
be cleaned regularly with the tooth-brush, or with a piece of lint 
fastened on to the end of a stick, and moistened with some 
mouth-wash. 

The hair should be carefully combed and brushed, and in 
female patients neatly plaited into braids. 

Bed-Sores : Prevention of. — The back should be examined in 
all cases of chronic illness, especially in those in which bed-sores 
are apt to occur, and systematically dusted with violet powder, or 
finely-powdered boracic acid. If necessary, the skin may be 
hardened by rubbing with spirits of wine, eau-de-cologne, or 
brandy. 

Changing Sheets. — In severe illness, this has to be managed 
without uncovering the patient or removing him from bed. It is 
best done from side to side in the following manner : — All the 
upper bed-clothes should be removed except the top sheet and 
one blanket ; the top sheet is then taken out, leaving the blanket 
next the patient 



GENERAL MANAGEMENT OF THE SICK-ROOM. 7 

To change the under-sheet the pillow must be removed, and 
the patient gently turned on his side to about the middle of the 
bed, the soiled sheet being folded close up to the patient's back. 
A clean sheet, half-rolled, is then placed against the soiled one, 
and the unrolled half is smoothly laid on the bed and firmly 
tucked in ; the patient is then turned over on to the clean sheet, 
the soiled one removed from the other side ; and the clean one 
then unrolled over the rest of the bed. When it is not possible 
to turn the patient on his side, the under-sheet may be changed 
in a somewhat similar manner from head to foot. 

To change the upper-sheet spread the clean sheet over the 
covering blanket, and whilst holding it with one hand draw out 
the blanket, then replace the remaining bed-clothes. 

Draw-Sheet. — This has constantly to be used in different cases 
in order to prevent the bed from being soiled. It consists of a 
small sheet folded lengthwise two or three times, so as to be of 
sufficient depth to reach from the middle of the patient's back to 
the knees. It should be firmly tucked in on both sides under the 
mattress, and when soiled it may be drawn away underneath by 
slightly raising the patient, and a clean part substituted, the soiled 
part being rolled up and pinned. It is preferable, however, to 
change the sheet altogether, and not to leave the soiled part 
inside the bed ; this may be done in the manner above described 
in changing the under-sheet. If the patient cannot be turned on 
one side, the nurse should carefully raise him, whilst an assistant 
draws underneath a clean sheet, which has been temporarily 
fastened to one side of the soiled sheet. The bed linen should 
always be aired and warmed before it is used, and the airing 
should be carried on in another room. 

Lifting and Moving the Patient in Bed. — The helpless patient 
requires lifting or moving from time to time, in order to alter 
the position, change the bed, or give the bed-pan. If the nurse 
is strong, she may be able to lift the body, single-handed, by 
passing her arms well underneath, one under the knees, the other 
under the back below the shoulders. Heavy patients may be 
moved and turned over on one side by means of the under-sheet 
or the draw-sheet. 

When a heavy patient has to be lifted any distance, several 
persons are required ; two of them join hands under the upper 
and lower part of the patient, while a third takes charge of the 
head. 

Bed-Pans. — Those made of earthenware are the cleanest and 
best. Two forms are commonly used, the round pan and the 
slipper : the former being suitable for men, the latter for women. 



8 A MANUAL OF NURSING. 

A flannel covering should be adapted to prevent the contact 
of the cold earthenware with the patient's body. The round pan 
can easily be passed from the side under the patient's body, which 
must be slightly raised. In order to pass the slipper, the patient 





Fig. 1.— Round Bed-Pan. Fig. 2.— Slipper Bed-Pan. 

lying on her back should draw up her knees ; and the thin end of 
the slipper can be gently inserted under the back. When removed, 
the pan should be immediately covered, and carried out of the 
room. 

Urinals. — Special urine-bottles should be obtained for male 
patients of such a form that the urine is prevented from flowing 
back into the bed. 

Disinfection. — After the bed-pan or urinal has been emptied, it 
should be well rinsed out with some disinfectant solution (carbolic 
acid 1-20), thoroughly cleaned with hot water by means of a bottle- 
brush or mop, and wiped quite dry. Disinfectant powder may 
be placed in the pan before using, but strong fluids are apt to run 
over the sides or otherwise reach the patient's skin, producing 
irritation and bed-sores. This disinfection should be rigidly 
observed in typhoid and other infectious cases. 

Excreta. — The excretions should on no account be allowed to 
remain in the room, or hidden under the bed. After being 
removed into the lavatory or closet, they should be kept covered 
and arranged for easy inspection by the medical attendant. 
Vomited matters should always be preserved, and the motions 
also in all cases connected with bowel or abdominal complaints. 
In any cases of doubt, it is wiser not to throw them away until 
they have been inspected. The urine should be saved at first for 
examination, and specimens when required from day to day. In 
all cases before operation, a sample of the urine should be pre- 
served. 

In infectious cases the excreta require special treatment (see 
Fevers). 

Feeding-Cups. — Patients unable to sit up in bed will have to 
be fed by a spoon, or, more conveniently, by a feeding-cup. This 
latter is simply a half-covered cup with a spout and handle, and 
when the patient's head cannot be raised from the pillow, the 



GENERAL MANAGEMENT OF THE SICK-ROOM. 



spout should have an extra curve, so that its mouth almost points 
downwards. Too much fluid should not be put in at a time, as 
it may run over the side when the cup is tilted. 





Fig. 3.— Feeding-Cup. 



fS- 

1 — 

1 
i. — 


1 





8 I 

4 
•3 

2 
1 i 




Fig. 4.— Medicine-Glass. 

A measured glass to contain two or three 
is useful in order to measure the quantity of 



Medicine-Glass. 

ounces of fluid is 

The glass is usually gradu 
ated, and marks the different-sized spoonfids and measures. 



Thus : §i ; or one ounce = two tablespoonfuls. 

5ss ; or half an ounce = one tablespoonful. 
3i 5 or one drachm = one teaspoonful. 
3ij ; or two drachms = one dessertspoonful. 
trti ; or one minim = one measured drop. 

A minim-measure, or a small measure-glass, should be used for 
drop-doses up to one teaspoonful. 

An ordinary wine-glass holds about two ounces, a small tea-cup 
four ounces, and a tumbler about half a pint of fluid. 

Hot-Water Bottles. — These vessels are essential furniture of 
the sick-room in cold weather, and should always be in readiness 
for warming the bed after severe surgical operations or in cases 
of collapse. They may be of metal or earthenware, and should be 
covered over with flannel; the india-rubber form is soft and 
comfortable. As a substitute in emergencies, hot bricks wrapped 
in flannel, hot bran-bags, or ordinary strong wine- or beer-bottles, 
filled with hot water and securely corked up, may be used, it 
being carefully ascertained that there is no leakage. 

Caution. — In giving hot-water bottles to unconscious patients, 
or those who are paralysed and have lost sensation, great damage 



10 A MANUAL OF NURSING. 

may be done by the nurse carelessly placing a hot bottle against 
the skin, and so producing a sore place or slough. In all cases a 
blanket should intervene, or the bottle should be placed so as not 
to be in immediate contact with the patient. 

Bed-Rest. — During convalescence, and for those who are 
obliged to be propped up in bed, some form of bed-rest is often 
necessary. Soft pillows act very inefficiently, becoming displaced 
in a short time. A firm support, such as the hinged bed-rest with 
cane- or carpet-back is the best, pillows being comfortably adjusted 
to the back and head. As a substitute, a light chair or stool may 
be placed between the pillows and the head of the bed. 

There is often a tendency on the part of the patient to slip 
down in bed, which may be partially obviated by a firm support 
at the feet; or, better still, by placing a long firm "roller pillow" 
under the buttocks, the ends of the pillow being securely fixed to 
the head of the bed by strong tape. 

Observation of the Sick. 

General Suggestions. — On the visit of the medical attendant, 
the nurse should be prepared to give an account of what has 
happened, or what she has observed during the time she has been 
on duty. True observation and correct statement of facts are 
only gained by practice and close attention, and, when carried out 
with precision and without exaggeration, are good proof of one of 
the most valuable qualities in a nurse. It is an excellent plan for 
her to write down her observations, and the time at which they 
were noticed, as it will assist her to give a clear report when 
required. At no time is a nurse expected to offer an opinion 
unasked about the facts which she has observed. 

As the result of experience, a watchful nurse will acquire some 
instinctive knowledge of her patients, and of the course of special 
diseases. She will be able to tell whether progress is being made, 
or whether her patient is getting worse, and to recognise some of 
the more important symptoms which denote the development of 
complications in the disease, and the peculiar effects of some 
remedies on susceptible patients. Lastly, she may gain a very 
valuable instinct which warns her that her patient is in danger, 
when this is not obvious to an inexperienced person, an instinct 
only gained after long practice and constant attendance on the 
sick. 

Definite instructions as to the diet, nursing, and medicines 
should be taken by the nurse when she comes on duty, and must 
be handed on by her to the nurse or attendant who relieves her. 



GENERAL MANAGEMENT OF THE SICK-ROOM. 11 

The nurse who is on duty at the time of the medical attendant's 
visit should be prepared with a report, not only of the hours 
during which she herself has been in attendance on the case, but 
also of the whole time since his last visit. 

Report. — The report should comprise the following points: — 

1. Temperature-chart and state of pulse. 

2. Bowels, action of. 

3. Sleep, hours of. 

4. Symptoms, notes of anything special, such as vomiting, rigors, &c, 

with the time at which each occurred. 

5. Diet, amount, and time at which taken. 

6. Medicine, time of giving, and effects noticed. 

In addition to the report, the excreta should be ready in an 
adjoining room for inspection. 

Administration of Food and Stimulants. — "When the patient 
is well enough to take meals, these should be brought punctually. 
They should be hot, and not lukewarm, and nicely and cleanly 
served. "When finished, the remains should be taken away at 
once, and not left about, creating an odour in the room. 

If the patient is able to sit up in bed for meals, these may be 
served on a tray or on a small bed-table. This table stands on 
four short legs, and one of its sides is scooped out. It is placed on 
the bed with the legs on either side of the patient's thighs, his 
body being received into the hollowed-out portion. A ledge 
running round the three sides prevents things placed on the table 
from slipping off. It may be used for various purposes. 

Feeding of Helpless Patients. — When a helpless patient requires 
to be fed, the nurse should gently raise him by passing the left 
arm behind the shoulders, or better, by passing the hand behind 
the pillow, and raising the pillow and head together, giving the 
fluid in a spoon or feeding-cup with the other hand. In all cases, 
a towel should be placed under the chin to prevent wetting the 
night-dress ; and the mouth should be wiped dry afterwards. 

Feeding in States of Exhaustion. — In cases of serious illness, 
nourishment may have to be given in small quantities and at 
frequent intervals. The nature of the food and the quantity 
should be previously ascertained from the medical attendant, and 
no other food should be given without his sanction. Feeding is 
often most difficult when most important, and the life of the 
patient may depend upon care in this respect. Two, three, or 
more ounces uf milk, beef-tea, or egg-flip, every two, three, or 
four hours, may be ordered, and it is sometimes impossible to per- 
suade the patient to take it. The nurse will thus have to use her 
discretion and her tact by varying the nourishment, or giving it 



12 A MANUAL OF NURSING. 

in smaller quantities oftener, thus managing to get down a fair 
amount in the twenty-four hours. A little stimulant given first 
may enable the patient to take nourishment better afterwards. 
When the mouth is dry and parched, or clammy with crusts or 
" sordes," it should be cleansed with lemon-juice and water before 
nourishment is given. 

During the night a nurse must use her discretion and avoid 
waking the patient out of a good sleep to administer nourishment; 
but in cases of great weakness patients should not be allowed to 
sleep long without support. It should be remembered that the 
early morning is a time when prostration is much more marked, 
and that some stimulant or nourishment is specially required then 
(see Nutrient Enemata). 

Stimulants should be measured and diluted with water or milk 
to the taste of the patient, and champagne may be diluted with 
Seltzer or Apollinaris water. They should be given at regular 
intervals, and alternate as far as possible with the nourishment. 

Administration of Medicines. — The following rules should be 
observed : — 

1. The directions on the label of the medicine bottle should 
always be read before giving the medicine, which should be given 
punctually at the times ordered. 

2. The dose must be measured accurately in a measure-glass, or 
by the marks on the bottle. 

3. Medicines and external applications, such as Liniments and 
Lotions, must not be kept near one another, as mistakes are apt to 
occur in the dark, and fatal poisoning has thus resulted in several 
instances. 

4. Medicine should be shaken before being poured out, and the 
bottle held with the label side upwards, to prevent the directions 
from being soiled and rendered illegible. 

5. The medicine-glass must be carefully cleansed after using, 
and oily or strongly-flavoured medicines should be administered in 
a glass kept separately for the purpose. 

6. The patient may wash out the mouth after taking nauseous 
or acid medicines, and a crust of bread or biscuit will assist in 
removing the taste. 

Times for giving Medicine, — When medicine is ordered to be 
taken three times a day without special directions as to the hour, 
it should be given about mid-way between meals — for instance, 
about eleven, four, and seven o'clock. During the night, sleep 
should not be broken in order to give medicines at the exact time, 
unless special orders have been given. There should always be 
an interval of not less than half an hour between the medicine and 



GENERAL MANAGEMENT OF THE SICK-ROOM. 



13 



a meal ; but cod-liver oil, malt, and tonics of iron and arsenic are 
usually prescribed on a full stomach, either at, or soon after a meal. 
Aperients are best administered the last thing at night, or early in 
the morning before breakfast. 

The effect of medicines should be carefully observed and noted 
down.* 

Arrangement of Room for Operation in Private Houses. — 
Slight operations, or those of minor importance, are performed 
while the patient remains in bed — this having been previously 
arranged with a mackintosh-sheet. 

For greater operations, or those taking a long time, or requiring 
good light, an operation-table can be devised. A firm wooden 
table about three feet high, four feet long, and two feet wide, such 
as a dressing- or kitchen-table, will answer the purpose, provided 
it be strong and steady. This should be furnished with blankets, 
pillows, and mackintosh-sheets, arranged as directed (see Opera- 
tion-Table). The table should be placed in a room with a good 
light, and near the window. It is convenient to use a room 
adjoining the bed-room, so that the patient does not see the pre- 
parations or instruments, but can receive the anaesthetic in bed, 
and then be carried into the operating-room. 



* ABBREVIATIONS The follow 

remedies are frequently appended to 
Stat, or statim sumendus 
Hora somni 
P. r. n., or pro re nata 
Omni nocte — omni mane 
Tertia quaque hora 
Quotidie . 
Semel, bis, ter die 
Repetatur 
Ssepe utendus . 
Applicetur lotio 
Regioni cordis or prsecordio 



ing abbreviations directing the use of 
prescriptions : — 

= to be taken at once. 

= at bedtime. 

= as circumstances arise. 

= every night — every morning. 

= every third hour. 

= daily. 

= once, twice, thrice daily. 

= repeat. 

= to be used frequently. 

= apply the lotion. 

= to the region of the heart. 



CHAPTER II. 

General Plan of the Human Body. 

Anatomy : — Skeleton — Skull — Spine — Vertebra — Thorax— Ribs — 
Sternum — Clavicle — Scapula — Humerus — Radius — Ulna — 
Carpus — Metacarpus — Phalanges — Pelvis — Femur — Patella — 
Tibia — Fibula — Tarsus — Joints — Muscles — Fat — Internal 
Organs — Nervous System— Respiratory System — Circulatory 
System — Digestive System— Excretory System — Work and Waste 
— Blood — Capillaries — Clotting — Blood Serum — Excretion — 
Temperature of Body. 

Anatomy is the science which treats of the structure, form, and 
position of the various parts of the body. The human body is 
obviously separable into the head, trunk, and limbs ; and if 
divided down the centre from before backwards by a vertical line, 
the two halves would almost exactly resemble one another. 

If the' limb of any animal be examined, there will easily be 
recognised an external covering of soft material, and of varying 
thickness, termed the soft parts, and an internal hard part consist- 
ing of bone. If the limb be dissected, and the skin with the fur 
be cut through and turned aside, the pale red flesh is seen under- 
neath, arranged in bundles or columns. On tracing these columns 
of flesh, they will mostly be found to terminate at one or both 
ends in a firm white cord attached to some part of the bone. 
These white cords are called tendons, and the columns of flesh, 
muscles. Between the muscles are soft white threads, the nerves, 
running down the limb and giving off fine branches. Close by 
the nerves are other threads, which are really hollow tubes or 
blood-vessels. These appear of dark-reddish colour when they 
contain blood, but are pale and flat when empty. 

All these together make up the soft parts, and they are loosely 
bound to one another by a fine delicate material called connective 
tissue, and are arranged around the central bone of the limb. 

The bones of the head and face, in like manner with the limbs, 
have their covering of soft parts, but here the bones are arranged 
in the form of a hard case enclosing a cavity, which contains the 
main organ of the nervous system, the brain. 



GENERAL PLAN OF THE HUMAN BODY. 



15 





Fig. 5. — Human Skeleton ; 
front view. 



Fig. 6. — Human Skeleton; 
back view. 



1. Skull. 5. Sternum. 9. Carpal bones. 13. Patella. 

2. Spine. 6. Scapula. 10. Metacarpal bones. 14. Tibia and Fibula. 

3. Clavicle. 7. Humerus. 11. Pelvis. 15. Tarsal bones. 

4. Ribs. 8. Radius and Ulna. 12. Femur. 16. Metatarsal bones. 



16 



A MANUAL OF NURSING. 



The trunk has its bony framework, and together with the soft 
parts includes a large cavity in its interior, which serves the pur- 
pose of lodging and protecting the various internal organs. 



THE SKELETON. 

The skeleton, or bony framework, forms the main support of the 
human body, and is composed of upwards of two hundred bones 
of various shapes and sizes — long, flat, and irregular (figs. 5, 6). 

Each bone has a covering of thin tough membrane, called the 
periosteum, wherein the blood-vessels which go to nourish the sub- 
stance of the bone are distributed. This bone-substance, or tissue, 
consists partly of animal matter, like gristle, and partly of earthy 
material, such as chalk and phosphate of lime, these latter giving 
the hardness which is characteristic of the bones of adults. In 

infants, the amount of 
this earthy material is 
much less ; their bones, 
accordingly, are softer and 
more easily bend and be- 
come curved. 

The skeleton includes 
the bones of the head, 
trunk, and limbs. 

THE SKULL (fig. 7) 
is formed of twenty-two 
separate bones. Eight of 
these compose the brain- 
case or cranium, and four- 
teen the face. 
Fig. 7.-SM1. The Cranium. — The 

bones of the cranium are — one Frontal ; two Parietal; two Tem- 
poral; one Occipital ; one Sphenoid; one Ethmoid. 

The Frontal bone forms the forehead, and surrounds the eye- 
sockets at their upper part. 

The Parietal bones form principally the crown and side-walls 
of the skull. 

The Temporal bones surround the ear, and contain in their 
interior the organ of hearing. 

The Occipital bone forms the back and part of the floor of 
the skull, and presents at the lower part a large round 
hole, the foramen magnum, through which the spinal 
marrow or cord passes from the skull to the spinal canal. 
On either side of this hole, on the under surface of the 




GENERAL PLAN OF THE HUMAN BODY. 17 

skull, are two smooth projections, which rest on the first 

or uppermost "bone of the spine. 
The Sphenoid bone forms also part of the floor of the skull, 

and its wings extend to the side-walls, acting in the 

manner of a wedge. 
The Ethmoid "bone is situated at the root of the nose. It is 

of spongy structure, and is perforated by numerous small 

holes, through which pass the nerves of smell to the 

nose. 

If the top of the skull be removed, and the hollow interior in 
which the brain is contained examined, it is seen to be of oval 
shape from before backwards. The vault and sides of the cranium 
are fairly smooth, but the floor or base on which the brain rests 
is irregular, with several projecting prominences of bone. The 
base of the skull is also perforated with numerous apertures of 
different sizes, in addition to the foramen magnum already men- 
tioned. These apertures serve for the exit or entrance of the 
several nerves and blood-vessels which have to pass through the 
skull to connect the brain with other parts of the body. Some 
especially may be noticed — for instance, one for the optic nerve 
leading through the back of the orbit to the eye ; another for the 
nerve to the ear in the ridge on the temporal bone ; and others, 
again, near the foramen magnum for the carotid artery, jugular 
vein, and the nerve to the heart and lungs. 

The Face is composed of fourteen bones, the more important of 
which are : — 

The Nasal bones, forming the bridge of the nose, and enclos- 
ing the cavity which contains the organ of smelL 

The Malar or cheek-bones. 

The Upper Maxillary, or upper jaw-bone, containing the 
upper teeth. 

The Lower Maxillary, or lower jaw-bone, containing the 
lower teeth. 

This is the only movable bone of the skull, and the joints 
are situated on either side of the base of the skull behind 
the ears. 

The bones of the skull and face together form cavities for the 
reception of the organs of special sense, viz., the orbits for the 
eyes, the nasal cavities for the nose, the mouth for the taste-organs, 
and other cavities for the organs of hearing. All the bones, with 
the exception of the lower jaw, are united by dented edges, fitting 
together and called sutures. 

In infancy, the bones of the skull do not meet at the top of the 

B 



18 



A MANUAL OF NURSING. 



head, and a soft place may be found there, under which the brain 
can be felt throbbing. This soft spot is called the fontanelle. 

THE TRUNK is naturally 

I divided into the chest and 



Spiaou3 - — 
process"" 



Atfas. 



I 7 Cervical 
( Vertebrae. 



12 Dorsal 
Vertebrae. 




It supports 
gives attach- 



the abdomen. 

the head, and 

ment to the limbs on either 

side. 

The Spinal Column (fig. 8), 
the central support of the whole 
skeleton, is a chain of thirty- 
three small bones, called ver- 
tebrae, which are placed one 
above the other : — 

The Cervical Vertebrae 
form the neck, and are 
seven in number. 
The Dorsal Vertebrae, 
or next twelve, carry 
the twelve ribs on 
either side. 
The Lumbar Vertebrae, 
five in number, are 
situated in the loin. 
The remaining vertebrae 
are united together 
in the adult, the 
upper five to form 
the sacrum, the lower 
four to form the 
coccyx or tail-verte- 
brae. 
If one of the vertebrae 
from the dorsal region be 
examined, the following parts 
may be noticed : — The body 
or solid portion ; a ring of 
bone, surrounding a central 
aperture ; and three spikes or processes (fig. 9). 

The vertebrae are placed one above the other so that their 
bodies form a strong continuous column, and their rings surround 
a central canal which extends through the whole length of the 
column, and in which is contained the spinal cord. Between 
each of the bodies is placed a cushion of gristle, called the inter- 



Ofl Coccygis. 



Fig. 8.— Spinal Column. 



GENERAL PLAN OF THE HUMAN BODY. 



19 




Fig. 9.— Dorsal Vertebra. 

a t body; b, transverse process ; 
c, spinous process. 

of the several vertebrae and 
spinal marrow contained in 



vertebral cartilage, which forms an elastic pad, preventing undue 
shocks or jars to the spine. 

The Processes project, one backwards in the middle, the 
Spinous Process ; and one on 
each side, the Transverse Pro- 
The projecting 



cess. ±ne projecting spinous 
processes can easily be seen and 
felt down the middle of the back 
in the naked body. These pro- 
cesses serve for the attachment 
of the powerful muscles of the 
back. 

The vertebrae are all firmly 
braced together by strong bands 
or ligaments, which, whilst per- 
mitting the various movements of 
the column, prevent displacement 
consequent injury of the delicate 
the spinal canal. 

The two upper vertebrae of the neck are specially modified for 
bearing the head, and for the performance of the more extensive 
movements in this region. 

The Sacrum, or rump-bone, is strong and massive, and well 
adapted to form the base and sup- 
port of the column. It gives 
attachment on either side to the 
hip- or innominate-bones, and these 
three, together with the coccyx, 
form a kind of basin called the 
pelvis (fig. 10). In the outer side 
of each hip-bone is a deep cup, 
called the acetabulum, which re- 
ceives the head of the thigh-bone. FlG - 10. -Pelvis. 

The Thorax or Chest is a cavity situated between the neck 
and the abdomen. It is formed by the spinal column behind, the 
sternum or breast-bone in front, and by the ribs on either side. 
This important cavity contains the heart, lungs, and large blood- 
vessels, and is separated from the abdomen below by a strong 
muscular partition, the diaphragm. 

The Ribs, twelve on each side, pass round from the dorsal 

vertebrae behind, and give strength to the side walls of the Thorax. 

The seven upper, or true ribs, are connected by their own 

cartilages directly with the sternum. The five lower are 

called false ribs, of these the upper three are connected 




20 



A MANUAL OF NURSING. 



only indirectly with the sternum ; while the two lower 
are quite free in front, and are termed floating ribs. 
The Sternum, or breast-bone, is the broad flat bone which can 
be felt in the middle of the front of the chest. It has attached to 
it the true ribs on either side. 

The Clavicle, or collar-bone, extends from the outer edge of 
the sternum to the shoulder. 

The Abdomen is formed by the lumbar vertebrae and lower ribs 
above, and by the pelvis below; the cavity being completed by 
the muscles and soft parts. It contains the bowels and various 
other viscera. 

yTHE LIMBS. — Two upper, the arms, and two lower, the legs, 
obviously exhibit a rough correspondence in their divisions, — the 
thigh and upper arm, the leg and fore-arm, the ankle and wrist, 
the fingers and toes. 

The Upper Limb is attached to the trunk by means of the 
shoulder-blade. 

The Scapula, or shoulder-blade (fig. 11), is a triangular bone, situ- 
ated at the back of the thorax, 
and covering the upper ribs. 
Its point and sharp edge may 
easily be felt on the back in 
the naked body. A cup-shaped 
depression may be noticed at 
its outer angle, the glenoid 
cavity, which receives the 
head of the upper arm-bone. 

The Humerus, or upper 
arm-bone, is one of the long 
bones. Its upper end, or 
head, is rounded, and fits 
into the glenoid cavity form- 
ing the shoulder-joint. Its 
lower end is shaped to re- 
ceive the upper ends of the 




Fig. 11. — Scapula, Clavicle, and Humerus. 

1. Scapula. 4. Ribs. 

5. Glenoid cavity. 



2. Clavicle. 

3. Sternum. 



6. Humerus. 



two bones of the fore-arm, and forms the elbow-joint. 

The fore-arm is composed of two bones, the Radius and the 
Vina (fig. 12). 

The Radius is attached to the humerus and ulna above, and 

expands below to carry the hand. 
The Ulna is connected by a hinge-joint with the lower end 
of the humerus, and projects backwards to form the 
prominence at the back of the elbow-joint, called the 
olecranon. 



GENERAL PLAN OF THE HUMAN BODY. 



21 



The Carpus, or wrist, is composed of eight small bones arranged 
in two rows, and with the lower end of the radius forms the 
wrist-joint (fig. 13). 




Fig. 12.— Radius 
and Ulna. 

1. Radius. 

2. Ulna. 

3. Olecranon, &c. 

4. Wrist-joint. 




Bones of Hand and Wrist. 



a t carpus ; b, metacarpal bones ; 
c, phalanges. 



The palm of the hand is formed by five longer bones called 
metacarpal bones, which fit on to the second row of the small 
wrist-bones. 

The Phalanges, or digits, constitute the fingers and thumb. 
Each finger has three digits, the thumb two. The last digit 
carries the nail. 

The Lower Limb is attached to the trunk by the pelvis. 

The Femur, or thigh-bone (fig. 14), is the longest and strongest 
bone in the body. Its upper end or head is rounded, and is 
veceived into the deep cup of the acetabulum, in which it is 
retained by a strong ligament called the round ligament. Its 
lower end terminates in two semicircular prominences called the 
outer and inner condyles, which rest upon the upper end of the leg- 
bone, and form the knee-joint. 

The Patella, or knee-pan (fig. 15), is a small three-sided bone 
lying in front of, and forming part of, the knee-joint; it is 
connected below with the leg-bone by a strong ligament. 



22 



A MANUAL OF NURSING. 




Fig. 15.— Patella. 



3 , 



The Tibia and Fibula are the two bones of the leg (fig. 16). 
The former is by far the stouter and stronger of the two, its 
front margin is very sharp and is known as the shin. 
The lower ends of the tibia and fibula project strongly 
on either side of the ankle-joint. 

The foot (fig. 17) is 
built on the same plan as 
the hand. 

The Tarsal bones are 
seven in number. 

The largest, or os 
calcis, projects 
backwards to form 
the heel; another 
fits between the 
lower ends of the 
tibia and fibula in 
the ankle-joint, and 
the rest are ar- 
ranged in rows to 
carry the next set 
of bones, the five 
metatarsal bones. 
These have each 
their three digits, 
which form the 
toes, except the 
first metatarsal 
bone or great toe, 
which, like the 
thumb, has only 
two digits. 
The hand and foot are 
admirably adapted for the 
In the hand, the bones 
of prehension, or grasp- 





Fig. 16. — Tibia 
and Fibula. 

1, tibia ; 2, fibula ; 
3, broad portion of 
tibia, forming part 
Fig. 14.— Femur. of knee-joint. 

work which* they have to perform, 
have greater mobility for the purpose 

ing, and the thumb can be easily apposed to any of the fingers. 
In the foot, they are firmly massed together to form a good 
support, and in walking the arch of the instep, situated between 
the heel and the ball of the great toe, enables the weight of 
the body to be received and distributed without risk of jarring 
or jolting. 

The Joints are devised to give easy movement between the 
bones which enter into their formation. There are several 



GENERAL PLAN OF THE HUMAN BODY. 



23 




Fig. 17. — Bones of Foot and Ankle. 

a, tarsus ; b, os calcis ; c, metatarsal bones; " 
d, phalanges. 



different kinds of joints. The hip-joint is a good instance of the 
ball-and-socket-joint, and is one of the most secure; the shoulder- 
joint, of the same 
kind, is much more 
liable to displacement 
on account of the 
shallowness of the re- 
ceiving cavity. 

Another form of 
joint is the hinge-joint, 
an instance of which 
occurs in the elbow. 
The ends of the bones 
which move one upon 
the other inside the 
joints have a thin 
covering of gristle 
or cartilage, and are enclosed in a kind of sac, which also lines 
the side walls of the joint, and contains a thin oily fluid, the 
synovial fluid, which lubricates the interior of the joint. In 
addition, the bones are held together by firm bands and coverings 
of strong membrane, called ligaments, 
which serve to keep them in their proper 
position. The movements of the joints 
are in great measure limited by the shape 
and nature of the bones of which they 
are composed ; some joints, like the 
shoulder, having very free movement in 
almost all directions; others, as the el- 
bow, being more confined. Extension 
or straightening, flexing or bending, 
rotation, and movement to one or other 
side comprise most of the ordinary move- 
ments of a joint. 

Muscles, or flesh, constitute a large 
portion of the soft parts of the body. 
By means of these are produced all 
the movements of which the organism 
is capable. A muscle is connected with 
the bone at one or both ends by a 
tendon; if one of these muscles be care- FlG - 18 '" M l fHand Ud Tend ° nS 
fully traced out near a joint, one end 

will be found to be attached to the upper bone, and the other 
end to the lower bone. !N"ow, when a muscle acts, it becomes 




u 



A MANUAL OF NURSING. 



thicker and also shorter, thus its ends approach nearer together, 
and with them the two bones to which these are attached, and so 

movement is pro- 
duced at the joint. 
All movements are 
produced by the 
shortening or con- 
traction of muscles, 
and this mechanism 
is variously adapted 
to the requirements 
of the different parts. 
The set of muscles, 
by whose action a 
joint is straightened 
-Flexion of Fore-Arm (after Huxley). or extended, are 

called extensors, those which bend the joint are called flexors. The 
muscles are of two varieties, voluntary and involuntary. 

The Voluntary muscles act under the influence of the will ; by 
them such movements as walking, grasping, &c, are produced. 

The Involuntary muscles are independent of the will, for 
instance the heart, and the muscles of the alimentary canal, 
arteries, and viscera. 

Fat, or Adipose Tissue, exists in the body in various situa- 
tions, and there is in all persons between the skin and the muscles 
a layer of varying thickness. It is also stored up in other parts of 
the interior of the body, assists in preserving the bodily warmth, 
and is in a measure an indication of the state of nutrition of the 
individual. 




Fig. 19. 



THE INTERNAL ORGANS 



The internal organs are contained in 



the interior of the several 
cavities which have been mentioned as included by the bones of 
the skeleton and the soft parts. They are grouped into different 
systems according to the nature of the work which they have to 
perform, thus: — 

The Xervous System. 

The Respiratory System. 

The Circulatory System. 

The Digestive System. 

The Excretory System. 

THE NERVOUS SYSTEM comprises the brain, spinal cord 
nerves, and the sympathetic system. 



GENERAL PLAN OF THE HUMAN BODY. 25 

The Brain and Spinal Cord constitute the central organs of 
the nervous system. They are contained in the long cavity and 
canal formed by the bones of the skull and the arches of the 
vertebrae which have been already described. 

The Nerves, slender white cords, serve to connect the central 
organs of the nervous system with all the distant parts of the 
body, tissues and organs of all kinds. 

The Sympathetic System to a great extent governs and con- 
trols the working of the internal organs in conjunction with nerves 
from the brain and spinal cord. It forms a chain of small masses 
of nerve matter and nerve-fibres on either side of the vertebral 
column, and from it numerous fine threads pass off to the different 
internal organs and along the vessels. 

THE RESPIRATORY SYSTEM.— The organs of respiration 
are the lungs. 

Lungs. — They are two in number, and occupy by far the greater 
part of the cavity of the thorax, lying on each side of, and partially 
covering over, the heart. The air-passages commence at the mouth 
and nose, and comprise the larynx, or voice organ, the trachea, 
or wind-pipe, and the two bronchial tubes. The larynx and the 
wind-pipe may be easily felt in the middle line of the front of the 
neck. The cartilage of the larynx is very prominent, and is 
popularly called "Adam's Apple" 

THE CIRCULATORY SYSTEM.— The main organ of the 
circulation is the heart. 

The Heart is situated nearly in the middle of the thorax 
between the two lungs. It is a muscular organ, and pumps the 
blood into the vessels, which are distributed through the most 
distant parts of the body. Those vessels which carry blood 
from the heart are called arteries; those which return it to the 
heart are called veins. 

THE DIGESTIVE SYSTEM commences at the mouth where 
mastication is effected. The food is then conveyed down the 
oesophagus or gullet. This tube lies in the neck, behind the 
wind-pipe, and in the thorax, close to the spine. It passes through 
a hole in the diaphragm and opens into the stomach. 

The Stomach is a bag in which the food remains for some 
hours; it opens into the intestines, or bowels, which finally 
terminate in the rectum. 

The Bowels form a tube between thirty and forty feet in 
length, through which the food is slowly passed along by a worm- 
like movement. They lie in coils, and occupy a large amount of 
the abdominal cavity. 



26 A MANUAL OF NURSING. 

The Parotid and Submaxillary Glands are salivary glands or 
organs which aid digestion, the former situated near the ear, the 
latter in the floor of the mouth. Each gland has a duct, or tube, 
through which the fluid is conveyed into the mouth. 

The Liver, the largest organ in the body, is of dark-red 
colour, and occupies the upper part of the right side of the 
abdomen, below the diaphragm and underneath the lower ribs. 
It makes or secretes the fluid called bile, which is stored up in 
the gall-bladder and is conveyed into the intestine from time to 
time. 

The Pancreas, or sweet-bread, lies behind the stomach, its tube 
or duct joining the duct from the liver. Its secretion is the 
pancreatic juice. 

The Spleen lies in close proximity to the left side of the 
stomach. It is of purple-red colour, and shaped like a pancake. 
It has no duct, and its exact function is doubtful. 

In addition to the separate digestive organs, the wall of the 
stomach and intestine contain small glands, which secrete fluid 
for digestive purposes. 

The Lacteals and Lymphatics are distributed in the walls of 
the alimentary canal, and assist ir absorbing the nutrient material 
after it has been prepared by digestion. The food enters these 
lacteals and is ultimately collected into a tube called the thoracic 
duct, which ascends the back of the abdomen near the spinal 
column, and finally opens into one of the large veins near the 
neck. The lymphatic vessels in their course frequently join 
small masses of gland-material called lymphatic glands, in which 
they become closely connected with small blood-vessels. 

THE EXCRETORY SYSTEM comprises the glands and 
their accessory parts, by means of which the blood is enabled to 
get rid of the waste products. 

The Skin contains in its deeper parts numerous small glands, 
sweat-glands, which excrete the fluid called siveat or perspiration. 

The Urinary Organs comprise the kidneys, ureters, bladder, 
and urethra. 

The Kidneys are the largest and most important of the excretory 
glands. They are two in number, of dark-purple colour, and 
in shape like a French bean. They are situated in the loins at 
the back of the abdominal cavity, one on either side of the 
lumbar vertebrae of the spine. A duct called the ureter passes 
down from each kidney and opens into the bladder. The bladder 
forms a bag, which lies in the pelvis in the lower abdomen. The 
urine is secreted by the kidneys, passes down the ureters, and is 



GENERAL PLAN OF THE HUMAN BODY. 



27 



collected in the bladder, being got rid of from time to time through 
the urinary passage or urethra. 



WORK AND WASTE. 

During life the body, or some part of it, is constantly moving 
and performing work, either obviously with the voluntary muscles, 
or less appreciably, as in the beating of the heart, the movements 
of respiration, and other vital actions which continue during sleep. 
This mechanical work involves a loss or expenditure of material, 
and a giving off of heat attended with the production of waste 
substances, such as carbonic acid and water, a chemical process 
similar to combustion. In order to prevent wasting, new material 
has to be supplied in the form of food and water ; and in order to 
preserve the heat of the body, the supply of oxygen must constantly 
be renewed, but waste-products injurious to it need to be removed. 

The same principles may be applied to the constituent parts of 
the body ; a single muscle, such as the heart or biceps, in doing 
work gives off heat, water, carbonic acid, and other waste-pro- 
ducts, and loses substance. It then requires to be built up again 
with new material, and to receive fresh supplies of oxygen, while 
the waste material has to be got rid of. 
The processes of combustion, nutrition, 
and excretion are thus brought into play 
in every muscular contraction. 

Blood and Capillary Circulation. — 
The changes which have just been de- 
scribed as occurring during a muscular 
contraction are brought 



about 



by the 




agency of the blood. The muscular tissue 
is permeated at every part by minute thin- 
walled tubes in which the blood circulates. 
The small arteries break up in the muscle, 
and divide and subdivide to form a fine 
branching net-work of minute tubes or 
capillaries ; these collect and form into a 
small trunk, the vein, which returns the 
blood to the heart. The muscle is by this 
means constantly supplied with a stream of fresh blood. All the 
tissues of the body are in like manner permeated by capillary 
blood-vessels. These can be easily studied by examining under the 
microscope the web of a frog's foot arranged in a suitable manner, 
when the blood can be seen coursing through the small channels 
(figs. 20, 21). 



Fig. 20.— Web of Frog's 
Foot. 



28 



A MANUAL OF NURSING. 



The blood is kept moving through the body by the action of 
the heart, which pumps out a certain quantity into the arteries at 




Fig. 21.— Capillary Circulation in "Web of Frog's Foot, seen under the 

Microscope. 

each beat, pushing onwards the column of fluid through the 
already full vessels into the capillaries. The veins receive the 




"Vein slit opcD and 
spread out. 



/A 



A 



Section of Vein, 
Valves closed by 
pressure behind. 



Ontside of Valve of Plan of Action o. 
Distended Vein. Valves. 



Fig. 22. 



blood, and their walls are provided at intervals with minute pocket- 
valves, which are attached so as to permit the passage of the blood 



GENERAL PLAN OF THE HUMAN BODY. 



29 




Fig. 23. — Blood-Corpuscles seen 
under Microscope. 



towards the heart, but which become filled out and obstruct the 
vessel if the blood flows in a backward direction (fig. 22). 

The Blood when drawn from the body in moderate amount is a 
fluid of deep-red colour, but it is pale when seen in a thin layer. 
If a drop be examined under the 
microscope (fig. 23), it will be seen to 
contain a multitude of minute bodies, 
or corpuscles, floating in the liquid 
part. These Corpuscles are of two 
kinds, red and white. The red are 
the most numerous ; they are very 
minute, of circular form, and flat- 
tened on either side, like a disc, when 
seen separately ; but they have a 
great tendency to cling together and 
look like rolls of coins. They im- 
part the red colour to the blood, 
and have the power of absorbing 
oxygen in large quantities, and distributing it to the various tissues 
of the body. The white corpuscles are larger than the red, but 
only exist in the proportion of three or four white to a thousand 
red. They are round, not flattened, but have the power of moving 
and of altering their shape. 

Clotting of the Blood. — Blood is fluid when first drawn, but 
soon becomes solid, unless it is stirred up, or constantly whipped. 
By beating or whipping up, a stringy substance called fibrin is 
removed, without which it cannot clot. If blood is allowed to 
remain standing for some time in a basin, the clot forms and then 
gradually contracts, while a thin yellowish fluid exudes, which is 
called the " serum." The clot itself is formed of corpuscles held 
together by the fibrin. While circulating through the heart and 
healthy vessels, the blood remains fluid; but in certain diseases, 
and under some conditions, it clots in the vessels and causes grave 
symptoms. Clotting of the blood is one of the most important 
agents in the arrest of haemorrhage. 

Blood Serum. — If the fluid which has exuded from the clot be 
put in a test-tube, and heated over a spirit lamp, it will soon 
become opaque, thick, and finally almost solid. Like the white of 
egg it coagulates on boiling, because it contains the substance 
known as albumen. Albumen is a proteid substance, and is 
chemically composed of nitrogen, carbon, hydrogen, and oxygen ; 
when burnt with oxygen, this latter unites with the carbon to 
form carbonic acid, and with the hydrogen to form water, and the 
nitrogen and hydrogen combine to form ammonia. This combus- 



30 A MANUAL OF NURSING. 

tion, or process of oxidation, of albumen is constantly going on in 
the tissues, and in the muscles whenever they contract, and is 
accompanied by the production of ammonia, carbonic acid, and 
water. The blood-corpuscles contain, besides albumen, small 
quantities of other chemical elements, such as sulphur, phosphorus, 
iron, potassium, sodium, calcium. 

Nutrition. — The blood supplies material for the nutrition of 
the tissues, carrying oxygen in the red corpuscles for oxidation 
purposes, and a store of material of various kinds, proteids and 
minerals, to help in building up and restoring the worn-out parts. 
The blood also requires to be fed, since it is constantly deprived 
of its oxygen and nutriment. Provision is, therefore, made for 
the restoration of its oxygen by means of respiration, while the 
nutritive material is supplied from the alimentary canal. 

The capillaries which line the walls of the minute air-vesicles of 
the lung are only separated from the air by the thinnest membrane, 
and the red corpuscles are thus enabled to absorb the oxygen from 
the air, carrying it to the tissues. The blood is also fed by the food 
after this has been digested and made soluble during its passage 
through the alimentary canal. The capillaries are disseminated 
through the walls of the different parts of the digestive tract, 
ready to suck in the nutritive fluids. Water is easily absorbed in 
large quantity to assist in supplying the fluid part of the blood, 
and some of the minerals and sugar are easily soluble and pass into 
the blood in a fluid form. The majority of foods, as meat, bread, 
starchy materials, fats and oils, have to be submitted to the secre- 
tions of the alimentary canal, and undergo digestion before they 
can be absorbed. 

The term osmosis is used to denote the property possessed by 
substances of passing through an animal membrane in a fluid or 
gaseous form, and it is by this process that the oxygen in the 
lungs, and the nutritive material in the alimentary canal, pass into 
the blood through the thin walls of the capillary blood-vessels. 
By similar means the interchanges between the blood and the 
tissues take place, only here the blood gives up its oxygen and 
nutriment to the tissues. 

Excretion is the process by which the body gets rid of the 
waste materials. In the oxidation or combustion of the tissues, 
such as takes place during a muscular contraction, certain waste- 
products are formed of no further use in the economy. Some of 
these — namely, carbonic acid, ammonia, and a substance, urea, 
closely allied to ammonia — are actually injurious, when accumu- 
lated in any quantity. The water, which is also a product of com- 
bustion, is got rid of in considerable quantity, holding in solution 



GENERAL PLAN OF THE HUMAN BODY 31 

much of the soluble waste material. The waste materials are 
excreted from the blood mainly through three channels ; the lungs, 
the skin, and the kidneys : — 

The lungs at each expiration send out air charged with car- 
bonic acid and water. 
The skin, by means of small glands embedded in it, called 
sweat glands, pours forth water containing in solution a 
small quantity of salts. 
The kidneys excrete the greater part of the water, and also the 
ammonia, urea, and salts. 

By these different means the blood coming from the tissues 
charged with waste-products becomes purified after it has passed 
through the capillary circulation in these excretory organs. 

Temperature of the Body. — A large amount of heat is pro- 
duced by the constant combustion of the food and tissues, and is 
distributed to all parts of the body by the blood-current. On the 
other hand, by the radiation of heat from the surface of the body, 
and by the warming of the cold air which is received into the 
lungs at every breath, the blood is robbed of its heat. There is 
then a source of constant loss as well as a constant supply of heat. 
If the temperature of the body in a healthy person be noted with 
a thermometer at different times in the twenty-four hours, it will 
be found to be approximately at 98° *4 F., showing that there is a 
regulation of heat in addition to production and loss. 

The temperature of the interior of the body taken in the mouth 
or rectum is nearly a degree higher than that of the surface, taken 
in the axilla or arm-pit. Again, there is a slight variation between 
the morning and evening temperature, the latter being, perhaps, 
half a degree higher. The temperature is commonly lowest at 
between four and six o'clock a.m., a time in the sick and aged 
when the vitality is at its lowest. 

In fevers and inflammation there is an increase in heat-produc- 
tion, and loss of balance in regulation, so that the temperature 
rises, and perhaps varies to the extent of several degrees at short 
intervals (see Fever), 



CHAPTER III. 

Diseases of the Nervous System. 

The Nervous System : — Brain — Spinal Cord— Membranes — Nerves — 
Motion — Sensation — Paralysis — Loss of Sensation — Reflex 
Action. 

Symptoms and Management of Brain Paralysis — Coma — Spinal 
Paralysis — Bed-Sores — Nerve Paralysis — Infantile Paralysis — 
Locomotor Ataxy — Meningitis — Cerebral Tumours — Epilepsy — 
St Vitus's Dance — Hysteria — Delirium— Delirium Tremens — 
Insanity. 

Introduction; — The Nervous System. 

The central organs of the nervous system, the brain and spinal 
cord, are invested with membranes, which form a complete cover- 
ing, and also line the interior of the bony cavity in which they lie. 

The Membranes are three in number, the Pia Mater, the 
Arachnoid, and the Dura Mater. 

(a) The Pia Mater, the innermost, is a delicate membrane, 
containing a large number of fine blood-vessels, which penetrate 
the substance of the nerve-matter of the brain and cord. 

(b) The Arachnoid lies between the pia mater and dura mater, 
and secretes a thin fluid called the Arachnoid fluid. 

(c) The Dura Mater, a strong tough membrane, lining the 
interior of the skull and spinal canal, forms a protective covering 
to the delicate organs, and contains numerous blood-vessels. 

THE BRAIN is divided into the Cerebrum (or Large Brain), the 
Cerebellum (or Little Brain), and the Medulla Oblongata (fig. 25). 

(a) The Cerebrum forms the greater mass, and is divided 
lengthwise by a deep cleft or fissure into two hemispheres; a 
band of nerve-substance, called the corpus callosum, joins these 
together. 

The outer surface of each hemisphere is mapped out into a 
number of folds, or convolutions, separated by clefts. In the 
interior, the brain-matter is white, and encloses the central cavities, 
which are a continuation upwards of a small channel in the centre 
of the spinal cord. Normally these cavities contain a small 
quantity of fluid, like the arachnoid fluid. 



DISEASES OF THE NERVOUS SYSTEM. 



33 



covering 



the 



COIl- 



The nerve-substance, or " grey matter, 
volutions on the exterior of the brain, is of grey colour, and 
differs from the deeper parts, which are 
white. 

From the under-surface of the brain 
may be seen white threads passing 
through the small holes at the base of 
the skull. These are the cerebral 
nerves ; amongst them are the nerves 
for smell, sight, and hearing. 

(b) The Cerebellum, or little brain, 
lies beneath the back of the large brain, 
and is also partially divided into halves. 

(c) The Medulla Oblongata is the 
continuation upwards of the spinal cord 
into the brain. It is about one and a 
half inch in length, is situated at the 
base of the brain just above the fora- 
men magnum (see p. 1 6), and is covered 
by the cerebellum. A large number of 
important nerves leave the brain at this 
spot, and the nerve-matter in its interior 
is so intimately connected with the 
regulation of the vital functions of the 
heart and lungs that destruction of the 
medulla is immediately fatal. 

THE SPINAL COED is a column 
of grey and white nerve-matter from 
sixteen to eighteen inches in length, 
extending from the top of the spinal 
column to the upper lumbar region, 
where it terminates in a fine thread. 
The membranes covering it are similar 
to those which have been described as 
investing the brain. 

In the centre of the spinal cord is a 
minute channel which extends along 
its whole length, and opens above 
into the cavities of the brain. Two 
fissures partially divide the cord into 
halves from above downwards — one Fig. 24.— Brain and Spinal Cord 
on the front, the other on the hind shown in Position, 

surface. Attached on each side are two parallel series of bundles 
of fibres, one set situated in a plane in front of the other. They 

C 




34 



A MANUAL OF NURSING. 



join together, and pass out of the spinal canal through apertures 
between the adjoining vertebrae. These two sets of fibres are called 




Fig. 25.— Brain seen from below. 

1. Fissure. 4. Pons. 

2. Nerve of smell. 5. Medulla. 

3. Nerve of sight. 6. Spinal cord. 

7. Cerebellum. 

the anterior and posterior roots, and they join together to form a 
spinal nerve. There are in all thirty-one pairs of spinal nerves. 

The Grey Matter lies in the interior 
of the cord, and when cut across has the 
shape of a crescent or half-moon in each 
half, joined by a central band. One 
horn of the crescent lies in front, and is 
Fig. 26.— Section of Spinal Cord connected with the fibres of the anterior 

root, the other receives the fibres of the 
a, anterior nerve root. posterior root of thespinal nerve (fig. 26). 
The Spinal Nerve, after leaving the spinal canal, divides and 
splits up into branches, which terminate in the muscles and skin. 




DISEASES OF THE NERVOUS SYSTEM. 35 

In the performance of any voluntary movement, such as that of 
a limb, all three parts of the nervous system — brain, spinal cord, 
and nerves — are concerned. The motor impulse, as it may be 
called, is started in the grey matter of the convolutions of the 
brain, traverses the tracts of white matter in its interior, through 
the medulla, down the spinal cord, and emerges at one of the 
anterior or motor roots of the spinal nerves, passing to the 
particular muscle, or set of muscles, which performs the necessary 
movement. It is possible by means of experiment to trace to a 
considerable extent the course taken by this impulse. For instance, 
it is found that the movements of one side of the body are chiefly 
governed by the opposite side of the brain, so that the nerve im- 
pulses must cross at some part. In the case of the motor impulses 
this crossing is found to take place in the medulla oblongata. 

If the path of the motor impulse is interrupted, either in the brain 
cord or nerve, loss of power of voluntary movement or paralysis 
occurs : thus, if the nerve to a muscle be cut, the muscle will be 
paralysed. In the same way, if the spinal cord be crushed, all the 
muscles below that part will be paralysed. Again, if the motor 
path in the right hemisphere of the brain be diseased or damaged, 
there will be paralysis on the left side of the body. 

The motor impulses have been shown to travel from the brain 
to the distant parts. A sensory impulse, or sensation, on the other 
hand, passes in the opposite direction. The prick of a needle on 
the skin sends an impulse travelling up a sensory nerve by the 
posterior root to the spinal cord; here it crosses over to the 
opposite side of the cord, and ascends to the brain. If a sensory 
nerve is cut, there is loss of sensation, or ancesthesia, in the part it 
supplies ; or, if the cord is destroyed, the body loses sensation 
below the injury. Destruction of the sensory path in the brain 
causes loss of sensation on the opposite side of the body. 

Thus, the spinal cord is seen to be a conductor of impulses both 
to and from the brain, but it also has, under certain conditions, the 
independent and peculiar power of reflecting a sensory as a motor 
impulse, a process to which the term reflex action has been applied. 
If, for instance, we tickle the sole of the foot of a patient who has 
received an injury damaging the spinal cord, the leg is immediately 
drawn up or moved ; yet the individual is unconscious of any sen- 
sation, and is quite incapable of voluntary movement in that limb. 

V Nervous Diseases : their Symptoms and Management 

The ordinary forms of nervous diseases with which a nurse 
should be acquainted may be arranged, for the sake of convenience, 



36 A MANUAL OF NURSING. 

into Paralytic Affections ; Chronic Diseases of the Spinal Cord ; 
Meningitis and Cerebral Tumours; Epilepsy, Chorea, Hysteria, and 
Insanity. 

(A) Paralytic Affections. 

The following are common instances of paralytic affections : — 

Hemiplegia, or Brain Paralysis ; 
Paraplegia, or Spinal Cord Paralysis ; 
Neuritis, or Nerve Paralysis. 

HEMIPLEGIA ( = a stroke on one side, or one half, of the body), 
Apoplectic fit, or a stroke, are terms constantly applied to this form 
of paralytic seizure. 

Symptoms. — The onset is sudden, and usually due to the 
bursting of a blood-vessel or the blocking of a vessel in the brain. 
The person may be in good health at the time of the attack, when 
suddenly he feels pain in the head and falls on one side, or, as 
frequently happens, falls down on getting out of bed. One side 
of the body is found to be paralysed, and perhaps to have lost 
sensation. The face may be drawn on one side, and if the 
paralysis is on the right side there is often loss of speech or 
aphasia. The attack may be attended with loss of consciousness, 
complete or partial, or the senses may be perfectly retained. In 
most cases, the loss of consciousness is temporary, but the paralysis 
continues for some time afterwards, gradually lessening until power 
is restored; or else the limbs remain in a state of incomplete 
recovery, accompanied, perhaps, with stiffness, contraction, or 
trembling. 

In severe cases, the loss of consciousness is more profound and 
increases, the breathing becomes heavy and stertorous, or "snoring," 
the face grows pale or livid, and after a time the patient dies. 

Coma. — The term " coma " is given to this condition of pro- 
found unconsciousness. In many cases of nervous disease, or 
other diseases in which death takes place through the nervous 
system, it is preceded by the onset of coma. 

During apoplectic fits the temperature remains unaltered or 
rises slightly, but in some fatal cases death is preceded by a con- 
siderable rise in the temperature. 

Management. — Shortly after the attack, the patient should be 
undressed with as little disturbance as possible, and placed in bed 
with the head slightly raised on a pillow. No stimulant need be 
given, especially if there is any insensibility. If there is profound 
coma with much stertorous breathing, and accumulation of phlegm 
in the throat when the patient is lying on the back, he may be 



DISEASES OF THE NERVOUS SYSTEM. 37 

turned over partially on one side, and kept so by means of pillows 
or some form of support. If the coma continue for any length of 
time, it is important also to ascertain if any urine has been passed, 
as the bladder will become over-filled, and constantly overflow, 
keeping the bed wet. The medical man should be informed of 
this and also of the condition of the bowels, that he may determine 
whether it is necessary to draw off the urine, or order an enema. 
As consciousness returns, there may be vomiting and some faint- 
ness, with confusion of the intellect, and if there is aphasia the 
patient is unable to explain what he wants, failing to find the 
right words to express himself, or making use of wrong ones. The 
nurse will soon be able to understand him by .means of signs. 
The nature of the diet, and the stimulant (if any is necessary), 
will be prescribed by the medical man. Milk or some other form 
of fluid nourishment may be given at first, and this, if there is any 
paralysis of the muscles of the face, may be noticed to dribble out 
of the mouth on the paralysed side. 

There is nothing special in the after-treatment that requires 
notice. The patient is, of course, more or less helpless, and care 
should be taken to keep the paralysed limbs warm, as they are apt 
to become cold. If there is loss of sensation in a limb, especial 
care should be taken in the use of hot-bottles or other hot appli- 
ances not to scald the skin, as the patient is quite unable to judge 
of the temperature : otherwise very troublesome sores may be 
produced. The nurse should first ascertain the temperature with 
the back of her own hand, and interpose a blanket or flamiel 
between the bottle and the patient's limb. 

Convalescence is often slow, and in favourable cases the leg re- 
covers before the arm ; in unfavourable cases great weakness and 
loss of power remain, and the limbs become stiff, contracted, and 
useless ; or the memory is defective, the mental powers fail, and 
imbecility supervenes. There is often a tendency to a recurrence 
of the fit. 

PARAPLEGIA, or spinal paralysis, may be sadden, and is due 
to inflammation of the cord, injury or disease of the spine, or any- 
thing causing damage to the cord. 

Symptoms. — In paraplegia there is loss of voluntary movement 
and of sensation below the diseased part, but reflex action may be 
obtained in the paralysed limbs. There is sometimes pain at or 
above the spot affected, extending round the body. 

Loss of control over the bladder and rectum is also observed ; 
the urine dribbles away, or the bladder may become full and 
then overflow, and the bowels may act unconsciously in the bed. 



38 A MANUAL OF NUKSING. 

There is, further, a tendency (much greater in some cases than 
in others) to the formation of sore places, or bed-sores, in the 
paralysed regions, on the back or sacrum, hips, shoulders, or heels, 
or any prominent part which presses against the bed. 

The course of the disease is usually long, and the symptoms are 
very distressing. In the more favourable cases recovery, complete 
or partial, takes place. In others, the inflammation spreads up- 
wards as high as the neck, and death occurs from paralysis of the 
diaphragm and respiration, or gradual exhaustion supervenes from 
bad bed-sores, inflammation of the bladder, or lung complications. 

The temperature is often above the normal, and when the 
disease affects the higher parts of the spine, remarkable elevations 
of the temperature are apt to occur. 

Management. — There are no cases more difficult to nurse well 
than bad cases of paraplegia, with great tendency to bed-sores. 
The sores may have begun or advanced to any stage in neglected 
cases before the nurse has to deal with them, and to cure them 
may seem hopeless. At first, the constant dribbling of the urine 
and incontinence of fasces greatly increase the liability to their 
formation, and together with the complete helplessness of the 
patient combine to make their avoidance almost an impossibility. 
But a very great deal may be done, and if the case is well managed 
from the beginning, and the proper appliances can be obtained, 
success is almost certain. 

Prevention of Bed-Sores. — Of first importance is prevention, and 
to attain this two main points should be attended to — to remove 
pressure ; to keep the patient dry. 

1. To remove Pressure. — The first may be best managed by placing 
the patient on a water-bed, or an air-bed, at the commencement ; 
failing this a water-cushion or ring-shaped air-cushion should be 
placed under the pelvis, and by this means any undue pressure at 
one spot will be prevented. If none of these appliances are to be 
obtained, the patient's position in the bed must be altered frequently, 
and pressure removed by ring-shaped pads adapted to encircle the 
prominent bone or tender spot. 

2. To keep the patient dry, a utensil of suitable shape may be 
arranged to catch the urine as it constantly dribbles away, and a 
draw-sheet smoothly laid under the pelvis, and moved when 
requisite (see Draiv-Sheet). 

The nurse should every day examine the back for tender or 
reddening spots, and should cleanse the parts with soap and water 
and dry them thoroughly, dusting with violet- or starch-powder ; 
or they may be rubbed with spirits of wine or brandy, which helps 
to harden the skin. Perfect cleanliness, dryness, and constant 



DISEASES OF THE NERVOUS SYSTEM. 39 

attention to the draw-sheet are essential. In any case, if the skin 
become red, or rawness appear, or if black spots or sloughs form, the 
medical man must be informed, as suitable dressings will be required, 
and the treatment should be carried on under his directions. 

The condition of the urine requires attention, as the bladder is 
very liable to inflammation, a state which is usually associated 
with turbid and offensive urine. The catheter has often to be 
used, and the bladder washed out. The urine should be saved, in 
order that it may be examined from time to time. One of the first 
changes noticed is that it becomes alkaline, and turns red litmus 
paper blue ; a smell of ammonia may be also observed, and a white 
sediment is apt to form at the bottom of the utensil ; all these are 
indications of bladder-trouble. 

NEURITIS, or nerve paralysis, is due to inflammation or disease 
of the spinal nerves. The most common cause is constant over- 
indulgence in alcohol, and the affection more often attacks in- 
temperate women than men. It may, however, also occur as the 
result of lead poisoning, cold, or an attack of diphtheria. 

Symptoms. — It commences with pains and tenderness in the 
legs or arms, with gradually increasing loss of power. It may 
progress until the patient is quite unable to walk, with tenderness 
and loss of sensation in the feet and legs ; the arms become affected 
in the same way, and more or less distortion of the limbs ensues. 
The intelligence is often obscured, the appetite impaired, and the 
digestive organs disordered. 

The greater number of patients recover partially or completely, 
even when bedridden and almost entirely paralysed, if proper 
treatment be adopted sufficiently early. In alcoholic cases total 
abstinence is essential. 

Management. — In the management of these alcoholic cases, 
especially in private houses, the nurse has to adopt every precau- 
tion, and to be constantly on the alert to ascertain that the patient 
(generally a female) does not continue to indulge her craving by 
means of friends or servants, as she will pursue any means to get 
the stimulant in some shape, and will take spirits of wine or eau- 
de-Cologne, if nothing else is obtainable. 

The feeding is very important, and as the appetite returns a 
liberal diet is usually recommended. There is often much wasting 
of the muscles, and general emaciation in these cases, and if the 
patient has to be confined to bed for any length of time, a water- 
bed is desirable. Mental derangement of various forms is not 
an uncommon complication in this disease, but is usually of a 
temporary character. 



40 A MANUAL OF NURSING}. 

When improvement commences, assistance should be given to 
the paralysed limbs and wasted muscles by shampooing, massage, 
and electricity, all of which have commonly to be applied by the 
nurse. To be thoroughly competent to manage these cases, there- 
fore, a nurse should have studied both massage and electricity 
(see Batteries and Massage). 



(B) Chronic Diseases of the Spinal Cord. 
This class includes such affections as : — 

Chronic Spinal Paralysis ; 
Infantile Paralysis ; and 
Locomotor Ataxy. 

PARALYTIC FORMS.— In these the chief symptoms are 
wasting and loss of power in particular groups of muscles, or the 
muscles of one extremity, and in extreme cases of nearly all the 
voluntary muscles in the body. 

The paralysis is often attended with distortion of the limb, due 
to the contraction of the unparalysed muscles, or the limb becomes 
rigidly bent at the joints, or there is shaking or tremor which 
cannot be controlled. 

Infantile Paralysis is a common cause of the many instances 
of club-foot which have to be dealt with surgically, and its onset 
is usually attended with a feverish attack, after which there is 
generally weakness in one or more limbs. 

Management. — The treatment of these paralyses frequently 
involves rubbing or electrical applications to keep up the nutrition 
of the paralysed muscles. In children, the distortion requires 
special boots or splints, or perhaps the division of tendons before 
it can be rectified. 

LOCOMOTOR ATAXY is the name given to a common disease 
of the spinal cord, because of its most prominent symptom, the 
pationt's inability to control or direct the movements of his legs in 
walking. 

Symptoms. — There may be various degrees of want of muscular 
control, from slight difficulty in walking in the dusk, in turning 
round quickly, or in standing upright with the feet together and 
the eyes closed, to the most exaggerated want of control of the 
muscular movements, the legs being jerked out in all directions in 
the attempting to walk. Other symptoms are — severe pains in the 
limbs, or in the abdomen ; impairment of sight and of sensation ; 
and bladder disorder. 



DISEASES OF THE NERVOUS SYSTEM. 41 

The malady is very chronic, lasting for years. In many cases 
there is some improvement or arrest of the symptoms if taken in 
hand early ; complete cure is rare ; in others there is slow progres- 
sion of the disease. 

Management. — Pains in the stomach and bowels, and in the 
limbs, are often some of the most distressing symptoms of the 
malady, and are very obstinate. The bowel-pains are sometimes 
increased by constipation, which may be relieved by aperients. 
Mustard-plasters may be applied to the stomach or limbs. 

The condition of the bladder is important, and it should be well 
emptied ; the use of the catheter may be necessary. Sore places 
and eruptions which require attention may appear, lest they should 
enlarge and form troublesome complications. 

Corns on the feet should never be cut, as deep ulcers are apt to 
follow. 

In all nervous cases, when there is much emaciation, precautions 
should be taken to avoid bed-sores, and, if the patient is likely to 
be entirely confined to bed, a water-bed is advisable. 



(C) Meningitis and Tumours of the Brain, 

MENINGITIS, or inflammation of the membranes of the brain. — 
The causes of meningitis are various. In many cases it proceeds 
from the spreading of inflammation from the neighbouring parts, 
either from disease of the bones, or of the dura mater of the skull. 
The extension of inflammation from disease of the bones of the 
ear inside the skull is a familiar instance. It may arise from 
blood-poisoning, blows on the head, or drink. 

Tubercular meningitis is a very common form of the disease. 
It occurs often in the children of consumptive parents, and attacks 
adults who are the subjects of consumptive complaints. 

Symptoms. — There may be considerable variety in the onset in 
different cases, and in the symptoms presented ; but the following 
may be taken as a fair example of a fatal case of meningitis, follow- 
ing ear-disease. A young man, who has had a discharge of matter 
and been partly deaf in one ear since an attack of scarlatina in 
childhood, is seized with violent headache and vomiting ; the pulse 
is 100, the temperature 104°, and he has some shivering. The 
tongue is foul, the bowels are confined, and the appetite is bad. 
He is irritable in manner, resents being disturbed, and is inclined 
to be delirious at night, though he does not sleep. The headache 
is intense and persistent, there is some intolerance of light, and the 
vomiting comes on regardless of food. In a clay or two he becomes 



42 A MANUAL OF NURSING. 

stupid and rather drowsy, and unable to see well. The pulse has 
become slower, 80 or 60, and the temperature remains about the 
same ; he is noticed to pick at the bed-clothes. A convulsive 
attack comes on and lasts for several minutes, and he is completely 
unconscious for some time after ; as consciousness returns, he is 
found to have some paralysis on one side of the face and arm. 
Further attacks of convulsions ensue, and he gradually becomes 
more deeply unconscious ; his breathing becomes stertorous and 
irregular, sometimes stopping for half a minute, and then becoming 
exaggerated. He passes everything unconsciously under him, the 
face becomes pale and dusky, profuse perspiration breaks out, and 
he gradually sinks, or dies in a convulsive seizure. 

TUMOURS OF THE BRAIN, arising from constitutional dis- 
eases, from an abscess, or from cancerous affections, give rise to 
symptoms of much the same kind as those referred to in menin- 
gitis, but the course is much less acute, and the disease may extend 
over months or even years. 

Symptoms. — The headache is often very intense, and may 
attack one particular part of the head : vomiting may be present 
or .absent, and the general symptoms are often obscure. There may 
be few or many signs of affections of the special cranial nerves, such 
as loss of eyesight, squint, or drooping of the upper eyelid, and loss 
of power in any of the voluntary muscles of the body occurs, or there 
may be loss of memory or mental derangement, or convulsive seizures 
limited to certain muscles, or affecting the muscles generally. 

Acute inflammatory affections of the head are very dangerous, 
but recovery takes places in a certain number of cases. The 
tubercular form of inflammation is, however, generally fatal. In 
some of the chronic diseases depending on particular constitutional 
poisons recovery takes place under treatment by appropriate drugs. 
In others, such as abscess and some kinds of tumours, an operation 
is performed by which the skull is opened and the abscess enabled 
to discharge, or the tumour is removed. 

Management. — The room which the patient occupies should be 
kept quiet, cool, and darkened, especially if there is intolerance of 
light. Headache is often one of the most distressing symptoms of 
the disease, and the hair will probably have to be cut, or the head 
shaved, and cold applications placed on it. The application of 
cold to the head may best be managed by means of ice broken up 
into small pieces and tied up in a bladder, the ice being renewed 
from time to time. Special ice-bags made of india-rubber are often 
employed. Less efficient substitutes are cold water applications, 
or lint steeped in evaporating lotions, all of which have to be very 



DISEASES OF THE NERVOUS SYSTEM. 43 

frequently renewed. In many instances, especially with children, 
it is impossible to keep the ice-bag or application in position, the 
head being constantly moved to and fro. If the cold application 
has to be persisted in, some other method must be adopted, such 
as an ice-cap, which fits on to the head, and through which a 
stream of ice-cold water can be kept constantly flowing, by means 
of tubes, from a receptacle above the bed into one below (see Ice- 
Bags). 

The removal of blood from the head by means of leeches is 
sometimes required, either from the temple or behind the ear (see 
Leeches). 

Feeding is best carried on by giving cold fluids, and iced drinks 
containing milk and soda-water, and to allay the vomiting small 
pieces of ice to suck are useful. An enema will probably be 
required for the bowels. 

If convulsive seizures occur, the nurse should watch them care- 
fully, noting, if possible, the part of the body in which they seem 
to commence, and whether they are confined to one particular part, 
or to one-half of the body and face, or whether they affect the 
body generally. Also she should observe the position of the head 
during the attack, and, if possible, the direction of the eyeballs, or 
anything else peculiar in the patient's appearance. It often 
happens that the nurse is the only person present who can give 
any intelligent account of the seizure, and her report may be of 
considerable value (see Epilepsy). 

In the course of acute head-affections, and sometimes even a 
short time before death, it may happen that a patient, previously 
quite unconscious, wakes up and takes notice of things around 
him, speaks to, and recognises his friends, appearing as if he were 
going to recover ; but shortly afterwards he relapses into a state of 
unconsciousness, from which he never recovers. This delusive 
amendment is not very uncommon, and is sometimes called the 
"lucid interval." 



(D) Epilepsy, Clwrea, and Hysteria. 

EPILEPSY. — Epileptic fits are commonly divided into two 
classes, the severe, or grand mal, and the slight, or petit mal. 
The severe form is attended with loss of consciousness and extensive 
spasm of the muscles. In the petit mal there is mere temporary 
loss of consciousness. 

Symptoms. — The severe epileptic fit is sometimes preceded by 
a warning, by which the patient knows that an attack is impend- 



44 A MANUAL OF NURSING. 

ing. The warning, or "aura," varies in character, from mere 
dizziness to a sensation commencing in an extremity, or at the pit 
of the stomach. At the time of the fit the patient perhaps cries 
out, and suddenly falls down ; his body and limbs become set fast 
in a violent muscular contraction, the head and eyes turn to one 
side, and the features are distorted. The face, pale at first, be- 
comes gradually livid as the respiration is stopped, and foam mixed 
with blood issues from the mouth. The pupils become widely 
dilated as the lividity increases, and the urine is perhaps passed 
unconsciously. The muscles then become slightly relaxed and 
jerky movements occur, the respiration commences again, the 
lividity lessens, and the spasm is at an end. The patient remains 
senseless and prostrate, and often passes off into a deep sleep for 
some time. In awaking it is found perhaps that he has bitten his 
tongue, and received other wounds or abrasions from his fall. 

In the slight fit, or petit mat, the individual loses consciousness 
for a brief interval, and perhaps stops in his occupation, looks 
strange or staring, becomes pale, and then recovers. He is often 
dull for a time afterwards, and unable to recollect what has been 
happening. Occasionally he becomes violent or maniacal. 

The severe and the slight fits frequently occur in the same 
individual. The petit mat is also common in children and young 
persons, and is apt to be mistaken for a fainting fit. Epilepsy may 
attack persons at any time of life, but its onset is most common at 
from ten to twenty years of age. It may be inherited, or it may 
be brought on by mental excitement or fright. There is sometimes 
only one attack, but more usually others follow. The night is a 
very common time for fits to occur. In some cases the fits do not 
occur again, but in the majority once established they are more or 
less likely to recur throughout life, probably lessening in frequency 
after middle age. The risk to life is not great, and the convulsive 
attack is rarely fatal. The main danger is from accidents, such as 
falling into the water or into the fire, or from the face becoming 
turned over on to the pillow, when the fit occurs during the night. 
The mental condition of the confirmed epileptic often deteriorates, 
varying from loss of memory and moral control to complete im- 
becility. The most serious and dangerous complication is Epileptic 
Mania, in which the patient becomes violent, and may commit 
assaults and murder. 

Management. — If the fit is preceded by a warning, the patient 
should be quickly put into a safe position, and made to lie down, 
the clothes being loosened about the neck and body. During the 
fit nothing particular can be done except to prevent the tongue 
from being bitten by placing a piece of india-rubber or several folds 



DISEASES OF THE NERVOUS SYSTEM. 45 

of a pocket-handkerchief between the teeth, the lower jaw being 
held down, and the tongue pushed in if it is already caught. After 
the attack the patient should be allowed to sleep for a short time 
if so inclined. Xo drink or fluid of any kind should be given 
during the fit. In some cases where the aura or warning begins 
in the hand or foot, a ligature may be tied tightly round the limb 
at some part above, as this occasionally prevents the convulsion. 
In the intervals, moderate bodily and mental exercise is good, and 
excitement should be avoided. Moderate diet with some animal 
food, abstinence from stimulants, and careful attention to the 
bowels is needful. An outdoor-occupation is best, and one in 
which 'the individual is not exposed in dangerous situations, in 
case of an attack. 

CHOREA, or SAINT VITUS'S DANCE, is a disease that 
occurs usually in young persons. It is more common in girls than 
boys, is sometimes brought on by mental excitement, school-work, 
or fright, and is frequently associated with rheumatism or 
rheumatic fever and heart-disease. 

Symptoms. — The first symptoms are often weakness and jerky 
movements of the limbs on one side of the body. The muscles 
of the face, too, are perhaps noticed to twitch, the lips are 
moved about, and there is a tendency to drop things out of the 
hand, and ordinarily quiet movements are performed in a jerky 
irregular manner. All these symptoms are increased by excite- 
ment and observation, and cease during sleep. They are often 
accompanied by mental dulness and general debility. 

In milder cases the movements are less violent, and perhaps only 
affect one side of the body, or are more marked on one side than 
on the other. 

In severe cases the jerky and irregular movements become ex- 
cessive, and there is complete loss of self-control ; the muscles of 
the trunk become involved, and the body and limbs are twitched 
and jerked about to such an extent that they become bruised and 
damaged by striking against surrounding objects; feeding becomes 
difficult, and sleep is interfered with. There is great weakness, 
and the mind is affected. In a few instances the patient becomes 
maniacal. This condition occurs more commonly in puerperal 
women, or male adults in a first attack. 

Young persons who have had one attack of chorea are very liable 
to a recurrence; but the majority get well, some in a few weeks, 
while in others the attacks are more obstinate. In adults the 
severe attacks sometimes terminate fatally; these are usually first 
attacks, and associated with mania or with heart-complications; 



46 A MANUAL OF NURSING. 

sometimes the patient dies from want of sleep and inability to 
take sufficient nourishment, or from bed-sores. 

Management. — Complete cessation from mental and physical 
fatigue is essential. Lessons should be discontinued, and emotional 
excitement and much playing with other children should be 
avoided. A temporary rest in bed is desirable and usually very 
beneficial, but should not be continued so long as to cause depres- 
sion. In weak pale children a good diet is essential. In severe 
cases when the movements are very violent, it is most important 
to prevent bruising and sore places which are very liable to occur, 
and prove very troublesome, or even the cause of death. For this 
purpose a padded room is desirable, or, in emergency, the adjacent 
articles of furniture should be removed, and the mattress placed 
on the floor in a corner of the room, the walls being covered with 
cushions or mattresses, and the limbs of the patient may be protected 
with pads of cotton wool, and gently held in check by the nurse. 
The feeding is very important and often difficult. The nurse will 
have to feed the patient with a spoon and steady the head, and 
assistance may be necessary. 

The bed should be kept scrupulously clean, as the evacuations 
may be passed unconsciously when there is much mental failure. 

HYSTERIA is the term applied to a disordered state of the 
nervous system which is far more common in women than men ; 
the term hypochondriasis being used for an allied condition in the 
male sex. It should be understood that the word "hysteria" 
implies medically a real malady, and is not employed to denote 
mere simulation of symptoms, or for imposture, as it frequently is 
by the public. It would be impossible even to mention here all 
the various phenomena which may occur in hysteria; in fact, 
there is hardly any function or organ which may not be implicated 
in different instances. 

Symptoms. — In the more ordinary class of cases, the individual 
exhibits continuously some mental peculiarity, either imperfect 
self-control, irritability, or depression ; on the other hand, in a 
few there is complete mental balance. Then from time to time 
there is a paroxysm or outbreak of hysteria, which may take 
some well-marked form and simulate one or another organic 
affection. For instance, there may be a convulsive seizure, 
paralysis, or vomiting. 

The patient will, perhaps, complain of the sensation of a lump in 
the throat, and a fixed pain in one temple, and there may be 
vomiting, or spitting of blood-stained juice in the morning ; she 
may refuse all food, and deny that she has slept for nights. The 



DISEASES OF THE NERVOUS SYSTEM. 47 

bowels are usually constipated, and the monthly periods often 
irregular. The urine is often copious in amount and very light 
coloured, and the patient may have the idea that she is unable to 
pass it. There is never incontinence. There is often a peculiar 
loss of sensation, affecting one limb or perhaps the whole of one 
side of the body, which has a remarkable tendency to change its 
position from time to time. There may be paralysis of one or 
more limbs, and rigid contractions of joints, with tenderness and 
great complaint of pain. Loss of voice, or a whispering voice, 
called "hysterical aphonia," is also common. The convulsive 
seizures or fits vary in character. In some the patient is boisterous, 
crying out and throwing the limbs and body about, but careful 
not to fall down and hurt herself ; obviously in full possession of 
her senses, conscious of pain when hurt, and exaggerating the 
paroxysms when under observation. In others the fits have a 
very close resemblance to an epileptic attack, and the term Hystero- 
epilepsy is applied to them. 

Management. — The attack will probably cease as soon as the 
patient is left to herself, and removed from observation, but will 
continue or increase as long as she is under the influence of 
anxious and sympathetic friends. The nurse should treat the 
patient with firmness and kindness, assuring her that there is no 
cause for alarm, and that the attack will soon subside. She may 
give a little water or sal-volatile, or distract her attention in some 
other way until she has calmed down. A cold douche of water or 
more severe measures should not be employed except under 
medical advice. 

In cases of imposture the nurse will have to watch the patient 
carefully, in order to assist in clearing up the doubtful symptoms ; 
for instance, she should watch whether patients who decline their 
meals contrive to obtain food by other means ; whether a limb 
supposed to be paralysed is moved when the patient thinks she is 
unobserved; or if blood expectorated is produced by artificial means. 

In hysterical aphonia and other hysterical affections the inter- 
rupted current is of great value, but should only be used under 
medical direction (see Batteries). 

Mental Derangements. 

DELIRIUM is an acute mental derangement occurring often in 
the course of the specific fevers, pneumonia, or other feverish 
states ; it is also common in brain-disease, kidney- and heart-affec- 
tions, in inanition consequent on wasting diseases, and after severe 
haemorrhage. 



48 A MANUAL OF NURSING. 

Delirium may be "quiet" or "active." In quiet delirium there 
are delusions of sight, the patient fails to recognise his friends, and 
he talks constantly in a low monotonous voice, a condition termed 
" low muttering delirium." In the "active delirium" the patient 
tries to act on his own ideas ; he may get out of bed, try to walk 
downstairs, put on his clothes, or attempt to jump out of the 
window; when more violent he may attack his attendants or 
commit suicide. 

In some there is "busy delirium" during which the patient is 
constantly moving about, under the impression he is at his work. 

DELIRIUM TREMENS is the result of alcoholic excess, or 
occurs in an intemperate subject in the course of disease or after 
severe injury. After a few days of disturbed sleep, loss of 
appetite, and irritability, the patient is attacked with delirium, 
horrible dreams, and visual delusions. He imagines he sees 
animals, insects, or devils in the room under his bed, and tries to 
brush them away. There is marked tremor about the hands, the 
lips, and tongue ; and the delirium is often busy, active, violent, and 
associated with extreme restlessness and picking at the bed-clothes. 
The temperature may or may not be raised, and should in all cases 
be tested by the thermometer. 

The majority of uncomplicated cases get well, others sink from 
exhaustion, an attack of pneumonia, or oth^r causes. 

Management. — Attendance on delirious patients requires the 
utmost tact, care, and watchfulness. The nurse should endeavour 
to humour them by listening to them, and must avoid annoying 
them by contradiction or harshness. They may often be persuaded 
into doing what is wanted by management, and by utilising their 
own ideas. 

The delirium of exhausting diseases and fevers is common at 
night, and may be diminished or controlled by the administration 
of food or stimulants at bed-time. In all cases sleep is of the 
utmost importance, and quiet should be obtained by the exclusion 
of friends, and the light may be obscured in the day-time. Tepid 
sponging or the application of cold to the head is often useful. 

In active or violent delirium measures must be taken to prevent 
the patient from injuring himself or his attendants. The fire-irons, 
knives, razors, or crockery will have to be removed from the room, 
and the windows securely fixed or fitted with stays to prevent the 
patient jumping out. More than one attendant may be required, 
or men should be ready within call in case of need, especially at 
night-time. For violent patients it may be necessary to have 
resort to mechanical restraint, by the strait-jacket, and the restrain- 



DISEASES OF THE NERVOUS SYSTEM. 49 

ing-sheet. The jacket is of canvas fastened with tapes at the 
back ; the sleeves are made to extend beyond the ringers, and 
should be tied up at the ends, and further secured by a bandage 
round the wrist. The patient is then placed on the bed with the 
arms crossed, and each hand is tied to the opposite side of the bed. 
A folded sheet is passed across the legs and ankles and fastened to 
the sides of the bed. The patient is covered in the bed-clothes, 
and the restraining-sheet is then fastened over the top to the bars 
of the bedstead, care being taken not to fix it too tightly over the 
chest. 

When all food is refused it will be necessary to feed with the 
stomach pump or with a tube passed through the nose. 

In delirium tremens it is of the utmost importance to the 
patient that he should be fed constantly, and this may be difficult 
as there is often great loathing of food. Stimulants must be with- 
held unless specially ordered. 

INSANITY. — Under the heading of Lunacy and Unsoundness 

of Mind may be included various mental disorders, to which 
different terms are applied, according to the special characters 
manifested in each. Mania, melancholia, dementia, paralysis of 
the insane, idiocy, and imbecility are some of the more common 
disorders. 

Management. — The treatment and management of these cases 
is usually undertaken in an asylum, as they cannot be satisfactorily 
treated at home. In cases of violence restraint is necessary (see 
Active Delirium). 

The laws relating to the custody of lunatics are very stringent, 
and certain formalities are necessary before a patient can be placed 
in a lunatic asylum. 

For a pauper lunatic, application should be made to the relieving- 
officer of the district ; and a certificate is required to be signed by 
a magistrate and one medical man. 

In private cases it is necessary for two medical men to examine 
the patient separately and sign the regular certificates before he 
can be removed to an asylum. 



i) 



CHAPTEE IV. 

Diseases of the Respiratory System. 

The Respiratory Tract and Respiration— The Lungs— Air-Passages 
— Larynx — Trachea — Bronchi — Mechanism of Respiration — The 
Respiratory Act — Importance of Ventilation — Cough and 
Dyspncea. 

Symptoms and Management of Laryngitis — Bronchitis— Asthma — 
Pneumonia — Pleurisy — Empyema — Pulmonary Consumption — 
haemoptysis or spitting of blood — and other complications. 

Introduction : The Respiratory Tract and Respiration. 

Reference has already been made to the scarlet-red colour of the 
arterial blood on its way to the capillary circulation, and to the 
purple or dark-blue tint of the venous blood as it returns to the 
heart. The change of colour takes place during the passage of the 
blood through the capillary circulation, and is due to the loss of 
oxygen which has been abstracted from it for oxidation in the 
tissues. At the same time, waste-products, such as carbonic acid, 
water, and urea have been entering it from all sides, so that the 
blood, on returning to the right chambers of the heart, is loaded 
with these impurities. 

Respiration is the process by which the impure purple blood is 
purified and replenished with oxygen, and the lungs are the 
organs which perform this function. 

THE LUNGS are two large spongy structures of pinkish colour, 
surrounding the heart, and occupying the greater part of the cavity 
of the thorax. The right lung is divided into three lobes, the left 
into two, and each lung has a covering of delicate membrane, 
called the pleura, which also lines the inner wall of the cavity of 
the thorax. The internal structure of the lung consists of a 
number of sacs or bladders, small air-tubes and blood-vessels, and 
the air finds an entrance to the interior by the air-passages, which 
first merit description. 

THE AIR-PASSAGES.— The air enters by the nose and mouth, 
then passes through the larynx down the wind-pipe or trachea. 
The Larynx, ^r voice-box, is situated at the top of the wind- 



DISEASES OF THE RESPIRATORY SYSTEM. 



51 



pipe, and can easily be felt as a hard prominence in the front of 
the neck, popularly called 
"Adam's Apple." In its 
interior are the vocal cords 
and the passage for air be- 
tween them is a narrow slit. 
The Trachea, or wind- 



pipe, 



is the continuation 




-e 



of the passage downwards, 
and is provided on the 
front and sides with rings 
of cartilage, which serve 
to protect and keep it 
open. Soon after entering 
the chest, the wind-pipe 
divides into two tubes, 
called bronchi, one going 
to each lung. The tubes 
and passages are provided 
with a soft lining, the 
mucous membrane, which 
exudes a fluid called mu- 
cus, serving to keep the 
surface slightly moist. FlG> 27. -Air-Passages and Lungs. 

The Bronchus, on a) larynx ; b, trachea ; c, bronchus ; d, sub- 
reaching the lung, divides divisions of bronchial tubes ; e, pleura, 
and subdivides into a large number of smaller tubes, and these again 
divide and subdivide into still smaller 
ones, while the smallest passages finally 
end in the minute air-sacs which 
make up the spongy lung-tissue. The 
lungs thus consist of millions of 
minute air-sacs, or vesicles, with 
small tubes opening into them, which 
are covered and surrounded by blood- 
vessels, and are only separated from 
the air in the interior of the air-sac 
by the thin wall of the sac itself. 

The blood-vessels, or small di- 
visions of the pulmonary artery, 
break up into capillaries in the 
walls of the air-sac, and carry the 




impure venous blood through this 



Fig. 28. 
small bronchial tubes joining 
air-sacs (highly magnified). 



delicate membrane, thus facilitating the exchange of gases between 



52 



A MANUAL OF NURSING. 



the blood and the air in the air-sac. The carbonic acid and some 
other impurities are removed, and the blood receives a fresh supply 
of oxygen from the air, and is then returned by the pulmonary 
vein as arterial blood to the left side of the heart, ready to be 
again distributed through the tissues of the body. It will be 
observed that in the lung is the only instance of a vein carrying 
arterial, and an artery venous blood. 



The Mechanism of Respiration. 

It is obvious that the air in the air-sacs of the lung must lose 
oxygen and become loaded with carbonic acid, requiring on this 
account constant renewal. 

The movements of respiration ensure the continuous passage of 
air in and out of the lungs in the following manner : — 

The cavity of the 
Thorax is an air-tight 
chamber, having for its 
floor the roof or arch 
of the Diaphragm. 
The lungs fill this 
cavity, having their 
outer surfaces closely 
applied to the walls of 
the cavity and to the 
diaphragm — not being 
adherent, but kept in 
contact by atmospheric 
pressure. 

During the process 
of breathing, the dia- 
phragm is constantly 
ascending and descend- 
ing ; by its descent the 
cavity of the thorax 
is enlarged, and by its 
ascent diminished. The 

lungs follow the move- 
A, expansion of chest in inspiration ; B, contraction ments f the chegt 
of chest in expiration [after Huxley). -. , , 

closely, becoming ex- 
panded when the diaphragm descends, and contracted when it 
ascends. This expansion and contraction of the lung causes a con- 
sequent entrance and exit of air, which constitutes respiration. 
In addition to the action of the diaphragm, there are other muscles 




DISEASES OF THE RESPIRATORY SYSTEM. 53 

which assist in the movements of respiration, — the most important 
being the intercostal muscles, which extend from rib to rib, and 
by their action draw up the ribs and help further to expand the 
cavity of the thorax. 

The Respiratory Act is divided into two parts — inspiration, 
during which the lung is expanding, and the air being drawn-in 
down the wind-pipe ; and expiration, during which the lung is 
contracting and air being forced-out of the wind-pipe. 

In a healthy adult, the number of respirations varies from four- 
teen to eighteen a minute ; in children from twenty to twenty-five ; 
while in infants, the number may amount to thirty or forty in a 
minute. But the number of respirations is greatly increased by 
excitement or exertion. 

Importance of Ventilation. — The expired air differs from 
the inspired, or pure atmospheric air, in the following particu- 
lars : — 

1. The air expired is nearly as hot as the blood, and contains 
almost as much watery vapour as it can hold. 

2. There has been, roughly speaking, a loss of five per cent, of 
oxygen, and a gain of five per cent, of carbonic acid. 

3. It also contains a greater quantity of decaying animal matter. 
It is estimated that about four hundred cubic feet of air are 

passed through the lungs of an adult taking no exercise, in the 
course of twenty-four hours. This air is charged with carbonic 
acid, watery vapour, and decaying animal products, and deprived 
of a large amount of its oxygen. It is clear, therefore, that the 
air in a small room with people in it soon becomes quite unfit for 
breathing, and requires constant renewal to prevent its becoming 
actually poisonous. The importance of ventilation in pulmonary 
affections, in which the air soon becomes vitiated, cannot be 
over-estimated (see Ventilation), 

Cough and Dyspnoea. 

These two symptoms are of common occurrence and of extreme 
importance in all affections of the respiratory organs. They present 
peculiarities in character according to the part of the tract affected, 
and may occur in disorders other than those of the respiratory 
organs — as, for instance, in disturbance of the digestive system. 
It is, therefore, necessary that a nurse should pay particular atten- 
tion to their special characters. 

A. COUGH is a violent expiration, in which the air is suddenly 
and forcibly expelled with a noise through the larynx from the 
lungs. The character of a cough varies considerably in different 



54 A MANUAL OF NURSING. 

ailments, and also in different individuals. The loudest and most 
noisy coughs are not always due to the most serious disease, and 
are often dependent on a disordered stomach or on hysteria. 

In laryngeal disease, the cough is often hoarse and croaking, the 
latter especially, if there is obstruction to the passage of air. 

In bronchitis, the cough may be attended with wheezing or 
rattling sounds. 

In pleurisy, the cough is usually short, sharp, and staccato. 

In ivlwoping-cough, a number of short coughs succeed one 
another, rapidly followed by a long-drawn inspiration — the same 
series being often repeated several times. The long-drawn inspira- 
tion may be crowing or " whooping " in character, or the whoop 
may be absent. 

B. DYSPNCEA, or difficulty in breathing. — In the simplest form 
the number of respirations is increased to twenty, thirty, or more 
in the minute, and the breathing is usually shallow in character, 
as in pneumonia. 

In laryngeal disease, inspiration may be difficult, and accom- 
panied by a whistling, crowing, or stridulous noise — a feature of 
great importance especially in children, as it indicates obstruction 
to the entrance of air through the larynx. 

In bronchitis and asthma, expiration may be difficult, prolonged, 
and accompanied by wheezing sounds. 

In some cerebral affections, or at the close of Bright 's disease, and 
in some heart-affections, a peculiar form of breathing supervenes, 
to which the term "Cheyne Stokes' breathing" has been applied. 
The respiration ceases at times altogether for a few seconds, and 
then recommences — being at first rapid and shallow, afterwards 
deeper and slower, and then ceasing again. 

Diseases of the Respiratory System. 

A nurse should be familiar with the commoner varieties of these 
affections — for instance, with the inflammatory forms attacking 
both air-passages and lungs, including Catarrh, Laryngitis, 
Bronchitis, Pneumonia, and Pleurisy ; also with Asthma and 
Pulmonary Consumption. 

CATARRH, or a cold, is the most common affection of the 
respiratory tract. An ordinary cold in the head is an inflammation 
of the mucous membrane lining the nostrils and upper part of the 
throat. The membrane is at first swollen and reddened, and then 
secretion takes place — the mucous fluid being poured out in a 
larger quantity than is normal. In most cases, a cold passes away 
without any special treatment, but it may be the commencement 



DISEASES OF THE RESPIRATORY SYSTEM. 55 

of a more serious illness. A neglected cold in a delicate person is 
liable to develop into one or other of the more severe inflammatory 
disorders of the respiratory system. 

LARYNGITIS is an inflammation of the larynx or voice-organ, 
and may result from cold and exposure or from an irritant, or it 
may supervene in the course of some other affection, such as 
tubercle or cancer. 

The inflammation affects the vocal cords, causing fever with 
hoarseness of the voice and cough, and there may be such narrow- 
ing of the orifice that the breathing becomes difficult, as in croup. 

Symptoms. — Dyspnoea, such as has been described, occurs in 
extreme cases ; there is great distress, the face is flushed and livid, 
the lips are blue and the eye-balls prominent ; the cough is harsh 
and croaking, often accompanied by mucous expectoration. The 
urgent symptoms have a great tendency to come on at night-time, 
or to increase during the night. In milder cases there is often 
fever with hoarseness of voice and cough, but no difficulty in 
breathing. 

There is always greater cause for anxiety in the case of children 
than of adults, the urgent symptoms of dyspnoea in the former 
arising rapidly and soon becoming dangerous. 

Management. — The temperature of the room should be main- 
tained at 65", and the air kept moist in the patient's neighbour- 
hood by means of steam from a bronchitis-kettle. 

The bed-clothes should be kept away from the mouth and nose, 
and the head and shoulders should be raised by means of pillows, 
if there is any difficulty in breathing. But if the symptoms of 
dyspnoea increase, the surgeon should at once be informed, as 
suffocation may be imminent, and tracheotomy prove necessary to 
save life. (See Tracheotomy.) 

BRONCHITIS. — Inflammation of the mucous membrane lining 
the bronchial tubes and their divisions is usually the result of 
cold, and may take either an acute or chronic form. 

(a) Acute bronchitis, if extensive, is a serious affection when it 
occurs in feeble old people or young children. 

The Symptoms are feverishness, dyspnoea, cough, and tightness 
on the chest. The dyspnoea is often considerable, expiration being 
difficult and accompanied by wheezing sounds. Cough is frequent 
with expectoration, and in the early stages the phlegm is white, 
watery, and frothy, as the mucus in passing through the air-tubes 
becomes mixed up with air-bubbles ; it is also occasionally streaked 
with blood. 

In the later stages, the phlegm increases in quantity, comes up 



56 A MANUAL OF NURSING. 

more easily, and becomes yellowish or greenish-yellow in colour, 
or else is viscid, tenacious, of dirty-white or yellowish appearance, 
and adheres closely to the sides of the vessel. 

The majority of patients recover in a few weeks, but when the 
inflammation spreads to the smallest bronchial tubes, or to the 
alveoli of the lung, causing broncho-pneumonia, the danger is 
greater, as this extension proves fatal in a large number of delicate 
or rickety children. 

(b) In the chronic form of bronchitis, the symptoms are of much 
the same character as in the acute form ; but the fever and the 
other symptoms are less severe though, perhaps, of longer duration. 
The chronic forms of bronchitis are often recurrent at the colder 
seasons of the year, and may become more or less permanent, 
complicated by over-distension of the lung or emphysema, asthmatic 
seizures, or dilatation and weakness of the heart. 

Management. — The temperature of the room should be main- 
tained at from 65° to 70°. Draughts should be avoided, and 
ventilation managed as far from the patient's bed as possible, the 
atmosphere being kept moist by means of steam (see Bronchitis- 
Kettle). 

The position most comfortable for the patient — especially if 
there is much dyspnoea — is on the back with the head and 
shoulders raised ; in some cases sitting up in bed is preferable. 
The sputa or phlegm should be noticed as to quantity and appear- 
ance, and the nurse should especially pay attention to the extent 
of lividity of the lips and face, or other symptoms of the 
dyspnoea becoming dangerous. 

The remedies in common use which will have to be administered 
by the nurse are — inhalations, poultices, and the medicines prescribed 
(see Inhalations, Poultices). 

The effect of these upon the cough, expectoration, and dyspnoea, 
must be noticed, and also whether nausea or sickness is produced ; 
if opiates are ordered, watch should be carefully kept against 
stupor, mental wandering, or increase of lividity. In cases of 
exhaustion, plenty of fluid nourishment will have to be adminis- 
tered, and stimulants if prescribed. 

During convalescence, the avoidance of chills is essential, as 
bronchitic patients are very susceptible to sudden change in 
temperature. On first going out, a respirator or some covering 
over the mouth is a useful precaution. 

ASTHMA, or asthmatic attacks, are often associated with the 
chronic form of bronchitis, but may exist independently in the 
spasmodic form. 



DISEASES OF THE RESPIRATORY SYSTEM. 57 

Symptoms. — An attack of asthma very commonly occurs in the 
night or early morning. The person wakes with a feeling of 
constriction about the chest, sits up in bed with the knees drawn 
up and the elbows on them, and begins to gasp for breath. The 
air is drawn in by a long, deep inspiration, the chest seems to 
remain expanded, the expiration is long and difficult, and attended 
with a wheezing or whistling sound. There is often a great desire 
for fresh air, and suffocation seems to be imminent ; but after a 
time the attack subsides, and, perhaps, a cough commences with 
some expectoration, or without this the breathing becomes again 
easy and natural. 

Management. — Asthma is more distressing than dangerous ; a 
fatal termination is very rare, so that the patient may be assured 
that the attack will pass off. Various remedies are employed in 
different cases, and many sufferers are acquainted with the 
remedies that relieve them most, whether it be a cup of strong 
coffee, the fumes of nitre papers, or of powders, a hypodermic 
injection of morphia, or the vapour of nitrite of amyl (see Inhala- 
tions and Throat- Applications). In many instances some error in 
diet is liable to start an attack, and this is especially the case with 
children, consequently such articles as sweets and jam should be 
avoided where there is a tendency to asthma. 

PNEUMONIA. — Inflammation of the lung-substance, like bron- 
chitis, is frequently the result of cold or chilling of the surface of 
the body, and is most common in the spring-time. It may also be 
produced by the inhalation of irritant particles, or poisonous gases, 
or it may arise as a complication in the course of rheumatic or 
typhoid fever, heart-disease, or any of the infectious fevers. 

In its acute form, attacking a healthy person, pneumonia 
presents well-defined characters, and runs a fairly definite course. 

Symptoms. — After a day or two of premonitory illness, the in- 
vasion of the disease is marked by a sense of chilliness or a sudden 
and severe rigor, or less commonly a succession of rigors. The 
temperature is found to be raised often to 103° or 104°, and this is 
accompanied by other signs of fever. In the course of the day, 
fresh symptoms supervene, such as rapid breathing, cough, and pain 
in the affected side. When the disease has developed, the patient 
lies in bed, usually on the back — the cheeks are flushed, the nostrils 
working, and sometimes a patch of vesicles of herpes appears about 
the lips. The respirations are shallow and rapid, out of proportion 
to the pulse and temperature (30-40 in the minute), and often 
accompanied by a sucking sound). 

There is usually cough, which increases the pain, and the ex- 



58 



A MANUAL OF NURSING. 



pectoratlon is viscid and tenacious. The colour of the sputum is 
often characteristic, being of reddish-brown, or rusty hue, due to 

the intimate admixture of 
blood. 

The urine is scanty and 
high - coloured, and the 
skin is dry, pungent, and 
sometimes slightly tinged 
with jaundice. 

Nervous symptoms in 
the form of tremulousness, 
and a tendency to de- 
lirium, especially at night, 
are often present. In 
favourable cases improve- 
ment takes place from the 
fourth or fifth to the eighth 
or ninth day, and the tem- 
perature comes down sud- 
denly at the crisis, the 
skin becomes moist, and 
the other symptoms of 
fever disappear (see fig. 
Fig. 30.— Temperature Chart. Acute Pneumonia 30). The cough, how- 
Crisis on 7th day. ever, often continues for 
some time, and the expectoration gradually diminishes and loses its 
colour. Cases vary extremely in severity, and in the more un- 
favourable ones the dangerous symptoms depend greatly on the 
condition and physique of the person attacked. 

In old and feeble people, death may take place from exhaustion ; 
the pulse becomes rapid and weak, and the appetite fails. The 
tongue is dry and brown, crusts appear on the lips, there is 
delirium, and the strength gradually fails. 

In persons of broken-down constitution there is danger of gangrene 
of the lung. The symptoms of general debility are present with 
those of pneumonia; but the sputum rapidly changes and becomes 
of "plum-juice," greenish, or dirty-yellow colour, and gives off a 
foetid odour. 

In drunkards the nervous symptoms of the disease are accentu- 
ated; tremulousness and delirium appear early, while in others 
delirium tremens, or mania of a violent kind develops (see 
Delirium Tremens). 

If the amount of lung affected be great, or the disease attack the 
other lung, there is danger of asphyxia and the symptoms indicat- 



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DISEASES OF THE RESPIRATORY SYSTEM. 59 

ing dyspnoea — such as rapidity of the breathing, with dusky com- 
plexion and profuse sweats — increase. The patient becomes rest- 
less, and wants to be lifted higher in the bed. 

In pneumonia secondary to rheumatic fever, or the specific fevers, 
the access is often very insidious — a rise in temperature with in- 
creased frequency of respiration being the only indications of the 
inflammation having attacked the respiratory organs. 

Management. — The nursing in pneumonia is of the highest im- 
portance. The patient should be placed in bed at once, and will 
soon find for himself the most comfortable position. The room 
should be warm and well-ventilated. The temperature, pulse, and 
respiration should be carefully registered, and the character of the 
cough, of the expectoration, and of any complaint of pain in the 
chest noted. The clothing on the bed should be light and warm. 
Absolute quiet should be insisted on, and the patient restrained 
from talking more than necessary. The diet should be fluid, and 
some beverage may be kept ready, as the patient often suffers from 
thirst. The pain may be relieved by mustard-poultices, and a 
cotton-wool jacket may be used to cover the affected side after- 
wards. Attention should be paid to the bowels, and a bed-pan 
should be used, as the patient is not allowed to get out of bed. 

The crisis may be expected with sudden fall of temperature, and 
moist skin from the fifth to the tenth day. 

AYhere there is great exhaustion in debilitated subjects, or feeble 
old persons, the strength has to be maintained by constant nourish- 
ment and stimulants. The delirium is often increased by weak- 
ness, and is especially troublesome at night. The character and 
smell of the sputum should be noticed, and, if offensive, should be 
disinfected or deodorised and constantly removed. Bed-sores 
should be guarded against by a water-bed or other means. 

In drunkard's pneumonia, if there is delirium tremens, or a 
tendency to violent mania in powerful patients, the nurse should 
ensure that there is assistance at hand in case of necessity, and 
this especially at night, to guard against damage to herself or the 
patient. Food should be administered freely, and stimulants if 
ordered. 

If sedatives or opium have to be given, the effect should be care- 
fully watched for symptoms of stupor, blueness, dyspnoea, or 
profuse sweating, and the dose omitted or lessened according to 
discretion, if there is no opportunity of referring to the medical 
attendant. 

PLEURISY, or inflammation of the pleura, or membrane 
covering the lung, may be due to cold or exposure, or may result 



60 A MANUAL OF NURSING. 

from injury to the chest or from broken ribs. It is also a com- 
plication of rheumatic fever, scarlet fever, and pulmonary con- 
sumption, and may be secondary to any inflammatory disease of 
the lung itself. 

Symptoms. — Inflammation of the pleura in the first stage is 
called "dry pleurisy"; the surfaces of the membrane are roughened, 
and are incapable of gliding easily over one another. The symptoms 
are — fever, sometimes preceded by a sense of chilliness, a short 
sharp cough, and acute pain in the chest. The pain is described 
as " stabbing " or cutting in character, and is increased by drawing 
a deep breath ; it is much intensified by any sudden expiration, 
as coughing or sneezing. The patient endeavours, as far as 
possible, to keep the affected side of the chest fixed, and usually 
lies in bed on the back, or on the sound side. The attack may 
not increase beyond the first stage, and with general treatment 
and counter-irritation gradually subsides. 

The pain may be lessened by the application of a few leeches, 
by a mustard-poultice, or by painting with iodine (see Leeches and 
Counter-Irritation). 

The second stage is that of effusion of fluid, or " pleurisy with 
effusion." The inflamed membrane pours out a fluid, which is 
received into the cavity of the pleura between the lung and the 
chest-wall. As the fluid increases, the lung is pressed on and 
collapses, the air being gradually squeezed out of it, until more or 
less of the lung is rendered airless, and therefore useless. If the 
fluid becomes excessive, other organs, as the heart or liver, are 
pushed out of place. The pleural cavity is capable of containing 
a large quantity of fluid, several pints in young persons, and 
several quarts in the full-grown adult. The symptoms of the 
second stage are usually characterised by diminished pain, but a con- 
tinuance of fever and increasing difficulty of breathing. There 
may be little or no cough. The main danger to be apprehended 
is from the dyspnoea, or faintness from embarrassed breathing and 
displacement of the heart. The patient will probably now be 
unable to lie on the sound side, since that side of the chest has to 
be left free to move, and to carry on all the breathing, as the 
affected lung becomes more and more pressed on by the fluid, and 
he may prefer to be propped up in the bed. 

Management. — The patient should be kept in bed, and any 
sudden movement or exertion avoided, as liable to increase the 
dyspnoea, or bring on faintness. It is usual to apply strong 
counter-irritation to the affected side by iodine, in order to 
promote the absorption of fluid. The bowels should be kept 
freely open, and the skin encouraged to perspire. If the dyspnoea 



DISEASES OF THE RESPIRATORY SYSTEM. 



61 



become at all urgent, the surgeon should be summoned, as relief 
from any danger can be afforded by the operation of tapping the 
chest. 

Aspiration, or tapping the chest, consists in the introduction of 
a hollow needle into the pleural cavity, between the ribs. A tube 
leads from the needle into a bottle, which can be exhausted by a 
pump. By this means the necessary amount of fluid is drawn out 
of the chest, and the needle withdrawn. If this operation is 
required, the nurse should have in readiness some carbolised oil 
for the needle, a measured glass (capable of holding a pint) to 
receive the fluid, and a pad of lint, with collodion and strips of 
plaster to close over the seat of the puncture. A few pieces of 




Fig. 31. — Aspirator. 

ice and salt to render the skin insensitive may be kept in readi- 
ness, and a broad flannel-bandage is sometimes applied afterwards 
(see fig. 31). 

In simple serous effusion, the fluid drawn off is seen to be 
watery, and of greenish or straw-coloured hue. Recovery may 
take place after one aspiration, but the operation may have to 
be repeated more than once. 



EMPYEMA is the term used when the fluid consists of matter, 
or " pus," and the case may have a somewhat different aspect from 
simple effusion. In young children pleural effusion is commonly 
purulent, and may arise after scarlet fever or other acute illness ; 
the fluid is very rapidly formed, and urgent dyspnoea soon super- 
venes unless relief is afforded. In adults pus is less common, and 
is rather an indication of a debilitated subject. The temperature 



62 A MANUAL OF NURSING. 

is often higher than in simple effusion, especially at night, and 
may be associated with hectic fever and rapid emaciation. 

Management. — The treatment adopted for empyema is to drain 
the pleural cavity, by means of a free opening and drainage tubes. 

Draining of the Pleural Cavity, — The operation is rather more 
extensive than aspiration. The patient is commonly given 
an anaesthetic, and the chest being uncovered, a mackintosh 
is arranged under the affected side, which should be previously 
cleansed with carbolic lotion. The nurse should be prepared with 
dishes of suitable shape, to catch the discharge of matter which 
issues from the wound, as soon as the pleural cavity is opened. 
Several india-rubber drainage tubes of various sizes should be 
ready in carbolic solution for insertion into the wound. A threaded 
needle and slips of plaster for maintaining the tubes in position 
should also be prepared. The dressings to be used should be 
ascertained beforehand from the surgeon, and as the discharge is 
very copious at first, and will soon work through, the wound will 
require dressing frequently for the first day or two. In all cases 
of operation for pleural effusion, the fluid withdrawn should be 
saved by the nurse, in order that it may be examined. The tem- 
perature of the body usually descends after the removal of the 
purulent matter from the chest, and when the fluid has freely drained 
away for a day or more, the temperature sinks to the normal. A 
fresh rise of temperature and return of feverish symptoms, would 
be an indication that there was some interference with the escape 
of the matter, possibly from the tube having become blocked with 
the more solid flakes of the discharge; or the matter may become 
offensive, and change from yellow to green or greenish-yellow, 
owing to an unhealthy condition of the pleural cavity, and it may 
be necessary that it should be washed out by the surgeon with an 
antiseptic solution. A funnel and an india-rubber tube are 
required for the purpose, and the antiseptic fluid should be ascer- 
tained to be of the right temperature, about 100° F., before its 
introduction. 

The shape of the chest, especially in children, is altered after 
empyema. The affected side becomes contracted and smaller, and 
the spine curved in cases of long standing. 

PULMONARY CONSUMPTION— PHTHISIS,— The popular 
term, " decline," is often used to denote this fatal malady, which 
carries off more victims than any other disease in this country. 
The disease-material is called tubercle, a little nodule deposited in 
the organ affected, which is most commonly the lung ; but it may 
attack almost any organ in the body, producing symptoms peculiar 



DISEASES OF THE RESPIRATORY SYSTEM. 63 

to the part attacked. The nodules may combine together in the 
lung to form masses, which create inflammation, break-down, and 
carry away parts of the diseased lung-tissue, leaving holes in the 
damaged lung. The tubercular-nodule has a great tendency to 
spread and infect neighbouring parts, and it may be carried by the 
blood into distant regions of the body, setting up inflammation in 
these also. Hereditary taint has been observed to exist in a very 
large number of those attacked ; but in addition there is often 
some other cause which has determined the onset of the malady. 
For instance, cold, want, over-work, drink, and excess, are some- 
times the exciting causes, both in the hereditary form and that 
acquired by disease. AYhen there is hereditary taint in both 
parents, the liability to its development in the offspring is much 
increased. 

Pulmonary consumption may be either acute or chronic ; in 
either form its symptoms may be very diverse in different indi- 
viduals. 

(a) The Acute Form more commonly attacks persons under 
twenty-five or thirty years of age, and may prove fatal in less than 
three or four months, or even in a few weeks. 

Symptoms. — The onset may be preceded by emaciation and 
cough, accompanied by sudden fever with rigors, and symptoms 
resembling those of pneumonia develop. The cough and sputum 
may be pneumonic in character, or denote bronchial irritation. 
The temperature is high, hectic in character, and there is a. 
tendency to lividity and sweats, along with great weakness, tremu- 
lousness of the limbs, and sometimes nocturnal delirium. A 
variety of other symptoms may be present, and apparent improve- 
ment take place for a while ; but the tubercular disease, once 
fairly established, soon terminates fatally. 

(b) Chronic Pulmonary Consumption, as the name implies, has a 
longer duration lasting from several months to years. The disease 
may commence at any period of life ; but the greater number of 
consumptives are attacked between the ages of fifteen and thirty- 
five. 

The onset is usually gradual ; a neglected cold, or a troublesome 
cough not much noticed, may be the starting-point. In other 
cases, spitting of blood, followed by cough, is the first indica- 
tion ; the cough increases and there is expectoration of yellowish 
or frothy sputum ; at the same time other symptoms begin to 
supervene. There are often gastric derangement with retching, 
white fur on the tongue, loss of appetite, and gradual emaciation. 

At night, or on awaking in the early morning, the body is 
covered with profuse perspiration. There is shortness of breath ; 



64 



A MANUAL OF NURSING. 



the sputum becomes thicker, and, when expectorated into the 
vessel, forms round masses of a yellow or greenish-yellow colour. 
From the beginning the temperature is often above normal, 
especially towards evening, and a bright flush is noticed on the 
cheek ; the pulse-rate is also increased. After a varying time, the 
symptoms begin to decrease, the night-sweats diminish, the appe- 
tite improves, the cough is less frequent, and there is less expec- 
toration. The patient gains flesh, and strength returns, though the 
cough may not altogether disappear. During all this time certain 



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Fig. 32. — Hectic Fever. Pulmonary Consumption. 

changes are going on in the lung. Tubercular material is being 
deposited in the upper part of one or the other lung ; this breaks 
down or softens, and is coughed up and expectorated through the 
bronchial tubes. This process is accompanied by the progressive 
symptoms above described. 'When this has been accomplished, 
and there is no further increase in the disease, the lung is left with 
a hole or cavity at that part, which gradually contracts and heals 
up in favourable cases, though the lung tissue is not reproduced. 
In a few instances, there may be no return of the disease, and the 
person lives on with a slightly damaged lung. In the majority of 
cases the improvement is only partial or temporary, and after a 
varying interval another portion of the same lung, or a portion of 



DISEASES OF THE RESPIRATORY SYSTEM. 65 

the other lung, is attacked in like manner, and a similar series of 
symptoms supervenes ; until, finally, the lung becomes riddled with 
cavities, and the patient sinks from exhaustion, or from one of the 
numerous complications incident to this disease. 

Management. — Those invalids who, for various reasons, are 
unable to leave England and seek a climate suited to their con- 
dition, should be recommended to make such changes in their 
mode of living as may tend to remove, as far as possible, any 
injurious influences which may have been productive of the disease, 
or which in any case serve to increase it. Amongst these hurtful 
influences are : — 

1. Occupations where dust or small particles fill the air, and 
cause bronchial irritation — for instance, the trades of stone- 
masons, miners, and grinders. 

2. Over-work, excitement, bad habits, such as indulgence in 
stimulants, and excess of any kind, are also predisposing causes. 

3. Defective ventilation and over-crowding, again, produce the 
same result, and are the most important factors in exciting 
tubercular complaints. 

On the other hand, ventilation and plenty of fresh air are 
potent preventives, and invalids should be instructed to keep their 
windows open in the day, and when possible at night, and should 
be encouraged to go out of doors when the weather is sufficiently 
fine. 

For the poorer classes an out-of-door occupation is the most 
healthy. A dry bracing atmosphere, with plenty of sun and 
free from wind, is the most favourable, and a residence situated 
on a hill, protected from the north and east, with a dry soil, is 
most suitable. 

Want of food and defective assimilation diminish the power of 
resistance and hasten the disease, and loss of flesh may precede 
the development of the consumptive symptoms when plenty of 
food can be obtained, but is not digested. A careful diet — with 
plenty of milk, cream, and butter — is suitable, but has to be varied 
according to idiosyncrasy. Cod-liver oil is commonly prescribed, 
and is best taken soon after a meal in orange-wine, lemon-juice, 
or some other vehicle, commencing with a tea-spoonful and 
increasing the dose to a table-spoonful or more, if it can be assimi- 
lated. Nausea and a tendency to diarrhoea would indicate that 
the dose should be diminished. 

Symptoms which call for special alleviation are — cough, high 
temperature, profuse sweating, and pain in the chest. 

Cough. — For this some linctus or cough-mixture will be pre- 
scribed by the physician ; or simple remedies such as barley-tea, 

E 



66 A MANUAL OF NURSING. 

black-currant tea, or equal parts of glycerine and water, may be 
given. A respirator of CoghnTs form, or one in which a few 
drops of some antiseptic solution can be introduced, worn in front 
of the mouth often relieves the cough. 

High Temperature and heat of the skin may be alleviated by 
tepid sponging, or different parts of the body may be so treated 
while the rest is kept covered (see Tepid Sponging). 

Profuse Perspiration. — Apart from the treatment by special 
drugs and tepid sponging, it is advisable that a light flannel 
garment should be worn next the skin, so that the moisture does 
not soak the linen night-dress, a source of great discomfort. The 
flannel should be changed and dried in the morning, or during the 
night in bad cases. 

Pain in the chest is usually caused by an outbreak of dry pleurisy, 
and may be relieved by the application of iodine to the skin over 
the painful part, or by some other form of counter-irritation (see 
Counter- Irritation). 

Complications of greater or less urgency, which require special 
attention, are liable to supervene in the course of pulmonary 
consumption. Pneumonia and pleurisy produce their particular 
symptoms, others, such as Haemoptysis, Pneumo-thorax, Tubercular 
laryngitis, Meningitis, and Ulceration of the bowels, require special 
mention. 

HAEMOPTYSIS, or spitting of blood, is a common incident in 
consumption, but may also occur in heart disease and congestion 
of the lungs. It is necessary to distinguish it from bleeding from 
the stomach or haematemesis (see Hcematemesis). The blood comes 
up in mouthfuls and is coughed up, not vomited ; it is bright red, 
often frothy, mixed up with phlegm, and the quantity of blood is 
variable. In slight haemoptysis there is a mouthful or two of 
blood occasionally ; in moderate cases a few ounces or a quarter to 
half a pint are gradually brought up at intervals ; in profuse 
haemoptysis a pint of blood or more is expectorated in a short 
time ; but in the suffocative form, the blood comes up so rapidly 
and profusely that it is inhaled back into the lungs with each 
inspiration, and death from suffocation takes place in a few 
minutes. 

Management. — The nurse may assure the patient that the bleed- 
ing will soon cease of its own accord, as it is sure to do in the 
majority of cases, and she will send for a medical man. 

In the meantime, the patient should be placed sitting up in 
bed, or on a chair, in a cool room. The dress may be loosened 
about the chest, and ice applied externally, while small pieces of 



DISEASES OF THE RESPIRATORY SYSTEM. 67 

ice are given to suck. 2so speaking, excitement, or moving 
about should be allowed. After the immediate attack has sub- 
sided, the sputum is usually blood-stained for some days. The 
diet should be light, without stimulants. The bowels should be 
relieved, and perfect rest maintained for some time afterwards. 
In fatal cases the rapidity of bleeding is so great that nothing can 
be done. The patient gets breathless, begins to look blue, becomes 
fidgety and very anxious, the eyes staring widely, the blood pour- 
ing from mouth and nostrils in a constant stream. Death takes 
place in three or four minutes from suffocation, and the urine and 
faeces are sometimes passed unconsciously in the bed. In profuse 
haemoptysis, the tendency to bleed is diminished when fainting 
and depression are induced. Great care should be taken not to 
excite a fresh outbreak by over-stimulation. 

PNEUMO-THORAX, or air in the pleural cavity, is a serious 
complication, produced by an opening in the surface of the lung, 
through which the air is able to pass out into the cavity of the 
pleura. This cavity becomes distended with air and the lung 
collapses ; this may occur suddenly, 

Symptoms. — After a sudden movement or exertion, the patient 
feels a sharp pain in the affected side, and suffers from shortness 
of breath. In severe cases the dyspnoea increases and becomes 
urgent, accompanied by lividity, perspiration, and collapse. 

The nurse should assist the patient into as comfortable a position 
as possible, and obtain assistance, since relief may in some cases be 
afforded by aspirating the chest and removing the pent-up air. 

TUBERCULAR LARYNGITIS.— The deposit of tubercles in 
the larynx, and consequent inflammation, add very greatly to the 
gravity of the disease, and tend to shorten the duration of the life 
to a considerable extent. 

Symptoms are — hoarseness, weakness of voice, and a husky 
somewhat metallic cough. 

The emaciation seems to progress more rapidly in these cases, 
and there is greater general weakness. The irritation in the 
larynx is a constant source of discomfort ; and when ulceration has 
taken place, there may be much pain, and perhaps difficulty in 
swallowing. 

Tubercular meningitis and tubercular ulceration of the bowels 
may supervene in the course of pulmonary consumption. The 
symptoms are described elsewhere (see Meningitis and Ulceration 
of Bowels), 



CHAPTER V. 
Diseases of the Heart and Blood- Vessels. 

Heart, Pericardium — Valves — Aorta — Pulmonary Artery — Sys- 
temic, Portal and Pulmonary Circulations — Movements of 
Heart — Pulse — Dyspncea — Dropsy— Ascites. 

Symptoms and Management of Pericarditis — Mitral Valve Disease 
—Aortic Valve Disease -Angina Pectoris— Fatty Heart — Con- 
genital Heart Disease — and Aneurysm of Aorta. 

Introduction : The Heart and Blood- Vessels. 

THE HEAET (fig. 33) is a pear-shaped organ, weighing, in the 
adult, from eight to ten ounces. It is situated nearly in the centre 
of the thorax behind the breast-bone, with the broad end or base up- 
wards and the pointed end or apex downwards and towards the left. 

The Pericardium is a thin serous membrane or bag, which sur- 
rounds the heart, and contains a small quantity of fluid, which 
lubricates the interior and permits the easy movement of the 
heart. 

The heart itself is of muscular structure of the involuntary kind, 
and contains four cavities in its interior. A partition from the 
base to the apex divides it into halves — the right side receiving 
venous, and the left side arterial, blood. Each half is again 
divided by another partition into an upper and a lower chamber. 

The two upper chambers are called the Auricles, the two lower 
the Ventricles. 

The Eight Auricle receives the two veins which bring the blood 
back from the upper and lower part of the body, and at its lower 
part is an orifice opening into the right ventricle, guarded by 
valves (fig. 34). 

The Eight Ventricle has thicker walls than the auricle, and in 
its interior may be seen the valves just mentioned. They are 
triangular flaps of delicate membrane, attached by thin threads to 
projecting pillars of the ventricle ; they are three in number, and 
called tricuspid. When the ventricle contracts, the valves are 
floated up and close the orifice between the auricle and ventricle, 
preventing the blood from passing back again. Another opening 



DISEASES OF THE HEART AND BLOOD-VESSELS. 



69 



in the right ventricle leads into the pulmonary artery, which also 
has three valves to guard its orifice. Each valve is half-moon 
shaped, or semilunar, and forms a pocket on the wall of the 
artery. After the ventricle has contracted, these three semilunar 
valves fill out, and their edges come together, thus preventing any 
return of blood into the ventricle. 




10 11 

Fig. 33.— Heart and Blood- Vessels. 

1. Trachea. 5. Aorta. 

2. Carotid artery. 6. Superior vena cava. 

7. Pulmonary artery. 

8. Pulmonary vein. 



3. Jugular vein. 

4. Subclavian vein 



9. Lung. 

10. Auricle. 

11. Ventricle. 



The Left Auricle receives the pulmonary veins from the lungs, 
and opens into the left ventricle (fig. 35). 

The Left Ventricle has a very thick wall, and is the most 
powerful part of the heart. The orifice from the auricle is guarded 
by valves similar to those in the right ventricle ; they are, how- 
ever, only two in number, and are called bicuspid, or mitral. The 
other opening from the left ventricle is into the aorta. 



70 



A MANUAL OF NURSING. 




Fia. 34.— Interior of Eight Side of Heart. 
pulmonary veins. 




Fiq. 35.— Interior of Left Side of Heart. 



DISEASES OF THE HEART AND BLOOD-VESSELS. 71 

The Aorta has thicker walls than the pulmonary artery, and its 
orifice is similarly guarded by three semilunar valves. Behind 
two of these valves are two small openings in the arterial wall, 
which are the mouths of the coronary vessels, through which the 
heart is supplied with blood. 

The Circulatory System. 

THE GENERAL or SYSTEMIC CIRCULATION com- 
mences with the aorta, one of the large vessels which springs 
from the broad end or base of the heart. The aorta leaves the 
left ventricle, and then forms an arch, from which important 
vessels are derived — namely, the carotid arteries to the head and 
neck, and the subclavian arteries to the upper limbs. The main 
trunk then descends through the thorax and abdomen, giving off 
vessels to the different viscera and to the walls of the trunk. In 
the pelvis it divides into two main trunks, which supply the two 
lower limbs. 

The blood-supply to the upper limb is carried by the subclavian 
artery, which passes through the arm-pit as the axillary artery, 
and on to the inner side of the arm, forming the brachial artery. 
At the elbow it divides into two branches, one, the ulnar, which 
descends along the inner side of the fore-arm ; the other, the radial, 
which passes down the thumb side, and unites with the ulnar in 
the palm of the hand, forming an arch, from which vessels are 
given off to the fingers. The pulse-beat in the radial artery may 
be easily felt in the wrist close above the thumb. 

The main artery to the leg is called the femoral, and can be felt- 
beating in the middle of the groin or hollow of the thigh ; the 
vessel then curves round to reach the back of the knee, where it 
is called the popliteal artery. It then divides into branches, which 
descend the leg and unite, forming an arch in the sole of the foot, 
from which the toes are supplied. 

The veins collect the blood from the capillaries through all the 
tissues of the body. The jugulars from the head and neck unite 
with the subclavian or veins from the arms to form the superior 
vena cava, a large trunk opening into the right auricle. The 
femoral veins from the legs pass up into the pelvis, and open into 
a large main trunk, the inferior vena cava, which ascends the 
abdomen, gathering veins from the interior and viscera before 
opening into the right auricle. 

The Portal Circulation is a branch of the general circulation ; 
the stomach, intestines, pancreas, and spleen receive their arteries 
from the aorta ; and the blood, on leaving these, is received into 



72 



A MANUAL OF NURSING. 




Fig 36. — Systemic Circulation. Aorta and Main Branches. 



DISEASES OF THE HEART AND BLOOD-VESSELS. 



73 



various veins uniting to form the portal vein; this enters the 
substance of the liver and breaks up into numerous capillaries. 
The blood is then collected by the hepatic vein, which opens into 
the inferior vena cava just before the vessel enters the right 
anno ip 

THE LESSER or PULMONARY CIRCULATION.— The 
pulmonary artery, carrying impure venous blood, leaves the right 
ventricle and divides into two branches, 
one for each lung. Inside the lung this 
vessel breaks up into small branches, 
which form a network round the alveoli, 
or air-cells. The pure oxygenated blood 
is collected by the pulmonary vein and 
carried to the left auricle. 

The Movements of the Heart. — In 
the healthy adult the heart beats from 
sixty to eighty times in a minute ; in 
children and infants the beat is more 
frequent, varying from a hundred to a 
hundred and forty in a minute. 

The two auricles contract together, 
and squeeze the blood into the ven- 
tricles ; the two ventricles then con- 
tract, and the tricuspid and mitral 
valves close their orifices, the blood 
being forced on into the large vessels 
— the pulmonary artery and the aorta 
— the semi-lunar valves then closing. 
The blood cannot get from the right 
side of the heart to the left without FlG# 37# 

passing through the lungs, or 

l . s. ». j? n i , a, pulmonary circulation ; o, por- 

circulation ; neither can the blood get tal circulation ; c, systemic 
from the left side of the heart to the circulation, 
right without passing round the general, or portal circulation. 
The beat of the heart is often perceptible against the front of 
the chest, especially when beating with undue force and fre- 
quency. 

The Pulse is caused by the alternate distension and contraction 
of the arteries at each beat of the heart, and this beat can be felt 
and counted in those vessels which lie near the surface of the 
body, such as the radial, carotid, or temporal arteries. The 
number of beats should correspond to those of the heart, and 
should be regular in time and force ; irregularity in this respect is 
a common feature of heart-disease. 




Diagramatic Represen- 
tation of. 
lesser 

a, pulmonary circulation ; b 

o e t tal circulation 



74 A MANUAL OF NURSING. 



Symptoms of Heart-Disease. 

In the different forms of heart-affections, there are many 
symptoms varying in character and importance which present 
themselves during the several stages of the disease, and which will 
be mentioned subsequently. There are two, however, in which 
the attentive care of a nurse is specially necessary, and which are 
commonly present, either separately or together, in the later stages 
of most forms of heart-affections — namely, dyspnoea and dropsy. 

Dyspnoea. — Management. — Difficulty of breathing in heart- 
affections is very much increased by exertion ; and when the 
patient is able to go about, he finds that walking uphill or hurrying 
produces palpitation and rapid breathing, which cease when he 
has remained quiet for a time. 

In more advanced cases, dyspnoea is apt to be a constant and 
distressing feature, even when the patient is in bed and quite 
quiet. There may be paroxysms of the bad breathing, and the 
respiration is often panting and gasping in character. The patient 
is intolerant of a recumbent position, and prefers to be propped 
up in the bed, with the shoulders well raised. Others have a 
great desire to get out of bed and sit in a chair, or to let their legs 
hang down ; the breathing may be much relieved by this position, 
care being taken that the body is properly covered up, and the 
legs wrapped in blankets. 

Dyspnoea from pulmonary congestion is a common complication 
secondary to heart-disease, and is usually accompanied by cough. 
The lividity in these cases is often very intense — affecting the 
lips, face, ears, hands, and feet. 

Dropsy is caused by the more fluid parts of the blood escaping 
from the blood-vessels and capillaries, and filling up the spaces in 
the connective-tissue of the body, or collecting in the cavities of 
the abdomen or thorax. Difficulty in the return of blood to the 
heart is a common cause of dropsy. 

(Edema is the term given to dropsy of the subcutaneous tissues, 
and by Ascites is understood a collection of fluid in the peritoneal 
cavity of the abdomen. 

Dropsy from heart-disease commonly appears first as a slight 
swelling about the ankles or insteps, which comes on towards 
evening ; if the parts are firmly pressed by the finger for a few 
seconds a dent is left. The swelling, or " oedema," may extend 
up the leg and appear in all parts of the subcutaneous tissues, 
being more marked where the skin is loose, as in the eyelids and 
scrotum. 

Management. — The dropsical condition is sometimes severe 



DISEASES OF THE HEART AND BLOOD-VESSELS. 75 

enough to prevent the patient from getting out of bed, or even 
moving himself in bed, and bed-sores are apt to form on parts 
where there is much pressure. 

Heavy and dropsical patients are very helpless, and the nurse 
requires assistance in moving and raising them. Some help 
may be given by a rope fastened to a ring firmly fixed into the 
ceiling above the patient's head, by which he is enabled to pull 
himself up by his hands. 

In some cases the skin, which has been first thoroughly cleaned 
and oiled, is pricked, or incised with a knife ; or small silver tubes 
are inserted and allowed to remain in, the object being to drain 
off the fluid from the deeper parts. 

The nurse will have to attend constantly to the bed, which 
becomes wet unless the exudation is soaked up in absorbent cotton 
wool, and she must watch the skin in the neighbourhood of the 
punctures, observing great cleanliness, as cellulitis or erysipelas is 
very apt to supervene. 

Ascites causes distension of the abdomen with fluid ; this dis- 
tension may become so great as to interfere with the breathing by 
pressing on the diaphragm. 

Management. — Tapping the abdomen may be necessary, for 
which the nurse should be prepared with a broad flannel binder of 
sufficient breadth to reach from the lower part of the sternum to 
the pubes, of sufficient length to pass once and a half or twice 
round the body, and arranged to fasten with safety pins or tapes. 
A pad of lint and strapping will be necessary for the puncture, 
and large pails to catch the fluid, which may amount to several 
gallons. In the case of a female patient, the nurse should draw 
off the urine immediately before the operation. The bed may 
be prepared with a mackintosh sheet under the body, and the 
patient should occupy a position on one side, so that the pro- 
tuberant abdomen projects over the edge of the bed. 

Diseases of the Heart. 

The common causes of heart-affections are — rheumatic fever, 
over-strain, bronchitis, and emphysema. Of these, rheumatic 
fever takes the first place. In the course of the fever, inflamma- 
tion may attack the valves or the pericardium, and lay the 
foundation of a disease that is permanent, and produces more or 
less obstruction to the circulation through the cavities of the heart. 

PERICARDITIS.— Inflammation of the interior of the peri- 
cardium interferes with the action of the heart, and is a common 
and serious complication of rheumatic fever, and of pyaemia. 



76 A MANUAL OF NURSING. 

Symptoms. — The symptoms of the acute form are — fever, pain 
in the region of the heart, difficulty in breathing, and feeble pulse. 
If effusion of fluid takes place, filling the pericardial sac, graver 
symptoms are present; the pulse is more affected, there is a tendency 
to faintness, and the dyspnoea is urgent and accompanied by 
lividity and sweats. The disease may begin very insidiously in 
children, and the inflammation may advance considerably without 
any special complaints having been made. 

Management. — Apart from the special management of rheumatic 
fever, patients suffering from pericarditis with effusion should not 
be allowed to sit up in bed, move suddenly, or exert themselves 
in any way, as fainting may be induced with fatal termination. 
For the relief of pain, blisters or some form of counter-irritation 
over the heart are useful (see Rheumatic Fever). 

VALVULAR DISEASE OF THE HEART.— As the result of 
inflammation of the valves, changes are produced which interfere 
with the circulation of the blood through the different orifices, 
and cause enlargement of the walls of the heart. There are two 
sets of valves which suffer in the majority of cases ; the mitral 
and the aortic valves. The course and symptoms of the two 
affections have in many respects quite different characters. 

MITRAL VALVULAR DISEASE. — Symptoms. — A large 
number of individuals suffer from minor degrees of disease of the 
mitral valve ; but are able to engage in the ordinary affairs of life, 
exercising rather more care than a healthy person. In this way, 
they may attain a fair age, though their lives are chequered with 
intermittent periods of illness. It is in the course of the many 
complications to which they are liable, or towards the end of their 
existence, that they require the care of a nurse. 

Complications of mitral disease are dropsy (see Dropsy) and 
congestion or inflammation of the lungs. 

The pulmonary complications are amongst the most common, 
and are caused by bronchitis or congestion of the lungs. 

The symptoms are — cough, difficulty of breathing, and lividity, 
with perhaps slight oedema of the feet, and a trace of albumen in 
the urine. 

Management. — A patient with mitral disease exhibiting these 
symptoms should stay in bed, keep to light diet, and take some 
aperient until the bowels are freely relieved. The attack may 
subside with these simple measures, or the symptoms may tend to 
increase, and the dyspnoea become more urgent. It is not un- 
common for haemoptysis to come on in these cases with sometimes 
considerable relief to the pulmonary symptoms (see Bronchitis, &c). 



DISEASES OF THE HEART AND BLOOD-VESSELS. 77 

Digitalis is a drug constantly employed in the treatment of 
heart-disease, steadying and strengthening the action of the heart 
and pulse, and increasing the quantity of the urine. 

Symptoms of Overdose. — The nurse should be acquainted with 
the symptoms indicating an overdose, or an accumulation of the 
drug in the system. In such cases the patient complains of nausea, 
loss of appetite, and a sense of flickering in front of the eyes ; he 
feels giddy and sick, and the pulse becomes very irregular ; vomit- 
ing and faintness may occur, and the urine is diminished in 
quantity. Patients taking digitalis, especially if the drug is being 
pushed, should remain in bed, or lie down, and avoid suddenly 
raising the head. If symptoms arise indicating an accumulation 
of the drug in the system, the nurse should omit the dose until 
the physician's visit. 

Fatal terminations in mitral disease are usually preceded by 
severe attacks of one or other of these complications, or by failure 
or dilatation of the walls of the heart. Sudden death in the 
ordinary acceptation of the term is uncommon. 

AORTIC VALVULAE DISEASE.— Males are infinitely more 
subject to this form of heart-disease than females. When severe, 
it is most dangerous to life, and sudden death is a not uncommon 
termination. It may result from overwork, rheumatic fever, or 
excess, and it may be associated with disease of other valves. 

Symptoms. — Persons suffering from this affection are usually 
pale, though well-nourished, and complain of shortness of breath, 
with perhaps pain in the chest and a feeling of faintness, especially 
on exertion ; sleeplessness and great restlessness are also common 
features. 

Management. — In aortic disease, sudden death may occur from 
syncope or faintness, and patients suffering from this disease should 
avoid hurrying, especially uphill, should eschew heavy or large 
meals, and excesses of any kind. If there is faintness, they should 
lie down, the head being placed as low as, or lower than, the 
body. 

ANGINA PECTORIS, or pain in the chest, is the name given to 
a painful and dangerous symptom, sometimes occurring in connec- 
tion with aortic disease, or some other heart-affection. 

Symptoms. — It is characterised by a more or less sudden spasm 
of pain in the region of the heart, with dyspnoea, and a sense of 
approaching death. The pain is of a peculiar nature, often de- 
scribed as "crunching," and radiates down the left arm to the 
fingers, and into the back, producing a sensation of numbness. In 
severe attacks the breathing is much affected, the face becomes pale 



78 A MANUAL OF NURSING. 

or livid, and is covered with drops of sweat. In a short time, the 
severity of the pains usually passes off; but in some instances the 
attack proves fatal. 

Management. — Since the attacks are very liable to occur after 
exertion, any unnecessary strain should be avoided. The state of 
the stomach seems in some cases to influence the attacks ; and 
heavy meals, especially at a late hour, are unadvisable. 

The greatest relief is sometimes experienced during the attack 
from the inhalation of nitrite of amyl. This fluid has the odour 
of pear-drops, and when a few drops have been inhaled, a warm 
sensation is felt over the surface of the body, and the face and 
neck become flushed, the spasm in many cases being cut short or 
immensely relieved by the inhalation. Five or ten drops may be 
used at a time on a pocket-handkerchief, and repeated, if necessary, 
until the full effect is produced, or relief gained. It is better for 
the patient to be recumbent when using the inhalation. 

DILATATION OF THE HEART AND FATTY DEGENER- 
ATION of the walls may exist apart from valvular disease, and 
are often fatal. 

The former may supervene upon long standing bronchitis and 
emphysema; the latter from drink and various other causes; both 
these affections frequently end in sudden death. Pulmonary com- 
plications or dropsy often appear at a late stage in the disease. 

CONGENITAL MALFORMATION OF THE HEART.— The 

subjects of this affection are born with an imperfect condition of 
the heart, the cavities being sometimes incompletely separated on 
the two sides. 

The marked features in these cases are — extensive blueness, 
lividity, and coldness of the lips, face, ears, and extremities. 
There is dyspnoea, and sometimes the ends of the fingers and toes 
are knobbed or "clubbed," as it is called, the last digit being 
rounded and larger than is normal. The majority of these patients 
die in childhood, either with convulsions or pulmonary complaints. 
They suffer much from cold and impeded circulation, and require 
to be well wrapped up, the extremities being kept warm. 

ANEURYSM is a disease of the arteries, and may affect almost 
any vessel, although it is much more common in regions where the 
artery is exposed to strain. Disease or an injury creates weaken- 
ing of the wall of the vessel, and bulging at the part affected. 
The swelling increases and forms a tumour, varying in size, in 
which pulsation can be felt. 

The aorta, subclavian, femoral, and popliteal arteries are com- 
mon sites for aneurysm. 



DISEASES OF THE HEART AND BLOOD-VESSELS. 79 

ANEURYSM OF THE AORTA is a very grave affection, and 
may produce a variety of symptoms from pressure on the many 
important structures near it. Amongst these, pain, difficulty in 
swallowing or breathing, loss of voice, and swelling of the arm 
and neck are not uncommon. Sudden death may occur from 
rupture of the aneurysm and haemorrhage into internal parts. 

Management. — Attempts are sometimes made to cure the dis- 
ease by absolute rest in bed, and restricted diet ; in these cases 
the nurse may have difficulty in ensuring that the patient attends 
to the rules and restrictions, which are irksome, and are perhaps 
infringed as soon as her back is turned. 

Aneurysm of the Vessels of the Extremities is treated 
by rest, or surgically by pressure or operation (see Pressure and 
Haemorrhage after Operation). 



CHAPTER VI. 

Diseases of the Digestive System. 

The Organs of Digestion— The Mouth— Teeth— Tonsils — Pharynx — 
Epiglottis — Parotid Glands — Gullet — Stomach — Liver and Bile 
— Intestines — Peritoneum — Foods — Digestive Processes — Lym- 
phatics—Indigestion — Vomiting — H2ematemesis — Jaundice. 

Symptoms and Management of Gastric Ulcer — Colic — Gall-stones — 
Peritonitis — Typhlitis — Intestinal Obstruction — Diarrhoea — 
English Cholera. 

The Organs of Digestion. 

The tube through which the food passes is called the Ali- 
mentary Canal, and consists of several divisions. The upper 
part into which the food passes from the back of the mouth is the 
Pharynx. Below the pharynx is the gullet or oesophagus which 
is situated in the neck behind the windpipe, and descending the 
hind part of the thorax pierces the diaphragm and opens into the 
Stomach. The stomach lies in the upper part of the abdomen 
and opens into the Intestine which finally terminates in the 
Rectum (see fig. 38). 

The Mouth. — The interior of the mouth should be inspected in 
order that the main features may be identified. 

The Teeth. — The complete permanent set in the half of each 
jaw counting from the middle line are as follows : — Two incisors, 
one canine, two bicuspids, and three molars, making in all thirty- 
two in both jaws. 

The tongue occupies the floor of the mouth and its surface is 
covered with raised papillae or projections, some at the back being 
of large size ; under the tongue is a thin band of mucous mem- 
brane, the fraenuni, and on either side of this may be seen the two 
small orifices of the salivary ducts, the glands of which are 
situated underneath the floor of the mouth. The palate, or hard 
part of the roof of the mouth, forms an arch between the upper 
teeth ; the soft palate, depending from the back, rises and falls 
with the breathing. The uvula hangs down as a projection from 
the middle of the soft palate, and on either side are the pillars of 



DISEASES OF THE DIGESTIVE SYSTEM. 



81 



the throat or fauces, from the sides of which project two rounded 
bodies, the tonsils. The posterior nares are the openings at the 
back of the nostril behind and above 
the soft palate. 

The Pharynx is the cavity at 
the back behind the fauces into 
which open the upper end of the 
windpipe and the top of the gullet 
(see fig. 39). 

The Epiglottis; situated at the 
root of the tongue is a flap of 
cartilage, hardly visible on looking 
into the inside of the mouth, which 
covers over the opening of the 
glottis or larynx in the act of swal- 
lowing, and prevents food from 
passing into it and " going the wrong 
way." 

foreign body, 
accident a 



If food, 
enters the 



or any 
larynx 



% 



choki 



violent expiratory effort, ' 
is produced to dislodge it. 

The Parotid Glands are situated 
one in front of each ear ; they are 
salivary glands, and their secretion 
is carried to the mouth by a duct 
which opens on the inner side of 
the cheek. It is the swelling and 
inflammation of these glands which 
produces the enlargement of the 
face in the disease known as 
"Mumps." 

The (Esophagus, or gullet, con- 
ducts the food into the stomach ; its 
length is about nine inches, and it is 
lined by mucous membrane. 

The Stomach is a large bag capable of holding two quarts ; it 
lies transversely below the diaphragm ; its left larger end being con- 
nected with the gullet ; the right is narrower and becomes con- 
stricted where it opens into the first part of the small intestine. 
The constricted portion is called the Pylorus or Pyloric Valve, 
and when closed prevents the food from passing out of the 
stomach. The mucous membrane of the stomach presents a 
honeycomb appearance, and contains millions of little tubes, 
which are really glands, producing a fluid called the gastric 

F * 




Fig. 38. — Alimentary Canal. 



82 



A MANUAL OF NURSING. 




juice, which is constantly poured out into the stomach, and cop- 
tains a substance, pepsin, which digests the proteids. 

The Intestines, or bowels, form the 
remainder of the alimentary canal, and 
are about thirty feet in length, being 
divided into the small and large in- 
testine. 

The Duodenum, or the first part of 
the small intestine, commences at the 
pylorus, and receives the bile duct. The 
remainder forms numerous coils termin- 
ating in the caecum, or first part of the 
large intestine, its orifice being guarded 
by a valve. 

The Liver is the largest gland in the 
body, and is situated below the ribs on 
the right side. It secretes the bile which 
is stored up in the Gall Bladder, on 
the under surface of the liver. The 
bile duct is joined by the duct from the 
Pancreas, another gland, and conveys 
the bile and pancreatic fluids into the 
duodenum (see fig. 40). 

Caecum and Large Intestine. — The 
first part of the large intestine, or the caecum, is a pouch situated 

in the right iliac re- 
gion. A small tube 
with a closed ex- 
tremity opens into 
the caecum, and is 
called the Vermi- 
form Appendix. 
The large bowel, or 
Colon, then ascends, 
crosses the abdomen 
above the navel, and 
descends the left side 
to end in the rectum 
or lower bowel, its 
orifice being con- 
trolled by muscular 
fibres or a sphincter 
at the anus. The 
interior of the intestines is lined by mucous membrane containing 



Fig. 39.— Vertical Section 
through. Face and Neck. 




Fig. 40. — Stomach and Duodenum. 



DISEASES OF THE DIGESTIVE SYSTEM. 83 

glands of various kinds in the different regions. Those in the 
intestine called Peyer's glands are noteworthy, as being inflamed 
in typhoid fever. 

The walls of the alimentary canal contain muscular fibres, 
which by their action cause a " worm-like " movement of the tube 
called peristalsis, the food being forced onwards. 

Peritoneum. — The many feet of bowel are coiled up, filling the 
greater part of the cavity of the abdomen, and are covered by a 
fine, delicate, elastic membrane, the " peritoneum," which also lines 
the interior of the wall of the abdomen, and serves to attach the 
bowels to the vertebral column. 

Food. 

The diet of a healthy individual is commonly a mixed did, 
and contains different forms of food stuffs. A fair average daily 
diet for a grown man would be — 

Bread, 12 ounces; butter, 1 ounce. 

Meat, 6 ounces (dressed) ; potatoes, 6 ounces (dressed). 

Eice, sago, tapioca, or bread pudding, 6 ounces. 

Milk, tea, or coffee \ beer 1 pint. 

A mixed diet should contain food stuffs capable of restoring 
the waste of the tissues, and keeping up the heat of the body. 

The different foods may be classified as proteids, fats, and 
amyloids. 

Proteids contain carbon, hydrogen, oxygen, and nitrogen ; 
under this head may be mentioned meat, flour, egg or albumen, 
cheese, gelatine, &c; being rich in nitrogen, they are sometimes 
called nitrogenous foods. 

Fats are composed of carbon, hydrogen, and oxygen, and include 
oils, vegetable and animal fatty matters. 

Amyloids contain less hydrogen than the fats, and comprise 
starch, sugar, bread, rice, sago, arrowroot, potatoes, &c. 

In addition to these food stuffs, water and minerals enter largely 
into the composition of the body. 

Digestive Processes. 

Digestion. — The processes in the alimentary canal by which 
the different food stuffs are prepared for absorption, and made use 
of in the economy of the body, are called "digestion." 

The proteids are acted upon by the gastric juice, which is acid, 
and contains the ferment pepsin ; the albumens being transformed 
into peptones. 

The fats are reduced to an emulsion by the action of the bile. 



84 A MANUAL OF NURSING. 

Of the amyloids sugar is easily dissolved, and requires no 
further change to enable it to pass into the blood. Starch, on 
the other hand, is useless and insoluble until it has been acted 
upon by the saliva, which contains a ferment, ptyalin, possessing 
the power of converting starch into sugar. 

During a meal, a mouthful of bread and meat, for instance, is 
ground up by the teeth, rolled over in the mouth by the tongue, 
and thoroughly mixed up with the saliva, which converts much 
of the starch in the bread into sugar. The mouthful is then 
swallowed and received into the stomach, where the gastric juice 
acts upon the proteids contained in the meat and bread, and con- 
verts them into soluble peptones. The food now rendered more 
fluid passes through the pylorus into the duodenum, where it 
becomes mixed with the bile and pancreatic juice. 

The bile converts the fats into an emulsion which can pass into 
the lymphatic vessels, and the pancreatic juice acts upon the rest 
of the starch which has escaped the saliva, and also assists further 
the other digestive processes. The food, now in the form of a 
creamy-looking fluid called Chyle, is forced onwards through 
the intestines by the peristaltic action, the most soluble parts being 
absorbed at once by the blood-vessels, while the fatty particles are 
taken up by the other vessels of the lymphatic system. 

Lymphatic System.— The mucous membrane lining the ali- 
mentary canal is abundantly supplied with minute tubes ; those of 
the intestine being called Lacteals, because the fluid they contain, 
and which they have absorbed from the chyle, is of milky appear- 
ance. The lacteals unite together to form larger vessels, which 
finally open into a duct called the Thoracic duct. The thoracic 
duct ascends the trunk in front of the spinal column, and opens 
into the left subclavian vein, pouring its contents of nutritious 
milky fluid directly into the blood stream. 

The water and minerals are readily absorbed by the blood- 
vessels without any further changes. 

Diseases of the Digestive System. 

DISEASES OF THE ALIMENTARY CANAL.— There are 
certain symptoms which are common to a large number of dis- 
orders of the digestive system, for instance, indigestion, vomiting, 
haematemesis, and jaundice. These may be considered separately, 
but they will receive notice under the particular diseases in which 
they occur. 

Indigestion, Dyspepsia, or failure of digestion, is indicated by 
a group of minor symptoms, one of the most common being pain 



DISEASES OF THE DIGESTIVE SYSTEM. 85 

at the chest or pit of the stomach. The pain varies in character, 
affecting the left side and the back between the shoulder blades, 
and it usually bears some relation to the meals and the kind of 
food eaten, commencing a few minutes or an hour or more after- 
wards. The tongue is often coated, and there may be loss of 
appetite, flatulence, and palpitation. Headache is common, asso- 
ciated with constipation, and nausea with acidity, and waterbrash 
may be present. Flatulence, or wind in the stomach or bowels, 
often accompanies the other symptoms of indigestion, and is apt 
to cause palpitation of the heart. 

Indigestion may be a symptom of grave disease of the stomach, 
such as ulcer or cancer, but commonly it is a functional disorder. 
The common causes of indigestion are — indigestible food, constipa- 
tion, chills, overwork, or excess in alcohol. 

Food may be indigestible from being improperly cooked or defi- 
ciently masticated, and the kind of food unsuitable to one dyspeptic 
may agree with another, so that no one rule applies to all cases. 

Management. — Inquiry should be made to ascertain the cause 
of the indigestion in order that it may be removed. A healthy 
mode of life, regular habits, and attention to the bowels are of 
first importance. AYhen there is much acidity or burning in the 
throat, sugars, sweets, and wines should be avoided. Flatulence 
is often increased by potatoes, green vegetables, or strong tea. 
Pain and a sense of fulness are frequently due to a large meal 
eaten hurriedly. 

Vomiting, or the ejection of the contents of the stomach by 
the mouth, is frequently preceded by a sense of nausea, and may 
be accompanied by faintness. In many cases it is an effort of 
nature to get rid of obnoxious material from the stomach, and the 
effect is salutary. In others it is a symptom of serious malady, 
either of the stomach or a remote part, but the sympathy of the 
stomach with other organs is so close that vomiting is a common 
accompaniment of disease of the brain, kidney, and uterus. 

In hysteria frequent vomiting may be naturally present, or it 
may be artificially produced by the patient by means of emetics or 
mechanical irritation of the back of the tongue or fauces. 

Management. — Points to be noted are the time at which the 
vomiting occurs in relation to food or to the kind of food ; whether 
the vomiting was preceded by pain, and whether the pain is 
relieved by vomiting ; whether the vomiting occurs at a particular 
time of the day, as, for instance, the early morning ; in suspected 
hysteria, whether the patient seems to induce vomiting by tickling 
the fauces or by efforts at eructation. 



86 A MANUAL OF NURSING. 

Matters vomited. — The vomit should always be inspected and 
put aside to be examined by the medical man. In many cases it 
merely consists of partially digested food, and has a sour smell- 
ing odour, due to the gastric juice. In continuous vomiting, there 
is often much bile mixed with the vomit, of yellow, green, or 
brownish colour. In the persistent vomiting of intestinal obstruc- 
tion, the fluid has a dark brown colour, is of the consistence of 
gruel, and very offensive, becoming faecal in odour in severe cases. 
In cancer and cases of dilatation of the stomach, the fluid is thrown 
up sometimes in very large quantities, a quart or more at a time. 
It is apt to remain in the stomach for a long time, until fermen- 
tation and some decomposition has taken place before it is ejected, 
and it is frothy and mixed with gas. 

Haematemesis. — Vomiting of blood is a common symptom in 
ulceration of the stomach, or in congestion from disease of the 
liver. The vomiting is often preceded by a sense of fulness or 
pain in the stomach, and some faintness ; on recovering the faint- 
ness the blood is promptly vomited from half a pint to a quart or 
more. The appearance of the blood varies slightly, it may be dark 
red, black, or dark brown in colour, like " coffee grounds," the dark 
colour being due to the action of the gastric juice, and there is 
often some food mixed with the blood. The attack may be and 
is usually a single one, but it may be followed by repeated haemor- 
rhage, and if profuse is dangerous to life. 

Management. — Xothing should be given by the mouth except 
a little ice or iced water, and in severe cases, where there is much 
syncope, the head should be kept low, and an ice bag may be 
placed over the stomach. For some time afterwards great caution 
should be taken in giving food by the mouth, the strength being 
maintained by nutrient injections. Haematemesis is often feigned 
by malingerers, or hysterical females, a small quantity of blood 
being ejected usually in the morning. The blood is produced 
from the mouth, throat, or gums, by sucking or wounding the 
mucous membrane. It has the appearance of plum juice, and is a 
glairy, watery fluid mixed with saliva. In some cases the haema- 
temesis is due to bleeding at the back of the nostril, the blood 
being swallowed during sleep, and vomited in the morning ; this 
is more apt to occur in children. After haematemesis the motions 
should be examined for blood (see Melcena). 

Jaundice. — A slight degree of jaundice accompanies several 
kinds of fevers, blood-diseases, and occasionally pneumonia. 
Intense jaundice occurs in diseases which obstruct or close the 
common bile duct, as in gall-stones. It is also present in vary- 



DISEASES OF THE DIGESTIVE SYSTEM. 87 

ing degrees in several of the diseases of the liver and alimentary 
canal. 

It is first noticed as a yellow tinging of the whites of the eyes 
and the skin of the body, and itching of the skin is often complained 
of. The urine is high coloured, amber coloured, or of various 
hues of dark green or dark brown, according to the degree of the 
jaundice. The sweat is yellow, and stains the linen. The motions, 
on the other hand, are of light clay colour, drab, or almost white, 
constipated, and unusually offensive. 

In cases of closure of the bile duct, the jaundice is intense, and 
the secretions correspondingly affected, with great depression of 
spirits, loss of appetite, nausea, and vomiting. There is emacia- 
tion, great weakness, and the itching of the skin is intolerable, 
and aggravated by warmth in bed. 

Management. — Some relief from the itching may be obtained 
by tepid sponging, or with a lotion of weak carbolic acid, or equal 
parts of glycerine and water. In jaundice due to chill or constipa- 
tion, the condition of the bowels requires constant attention, and 
in most cases the bowels are confined. 

GASTRITIS AND GASTRIC ULCER.— Ulcer of the stomach 
is prone to attack young women suffering from anaemia. The 
patients are not uncommonly domestic servants of pale aspect, who 
suffer from chronic indigestion. 

The Symptoms of gastric ulcer are mainly those of indigestion, 
but the pain is usually much more acute, with tenderness over the 
pit of the stomach, and intolerance of pressure. The pain is 
aggravated by solid food, and vomiting often relieves the pain. 
In some cases there is an attack of hsematemesis, followed by 
melsena (see Hcematemesis). 

Perforation of the Stomach is a catastrophe which occurs in a 
certain number of these cases, and is fatal either within a few 
hours from collapse and shock, or subsequently in a few days 
from severe peritonitis. 

The patient, usually a young woman, with symptoms of gastric 
ulcer, or indigestion, is attacked after a meal with severe agonising 
pains in the abdomen, attended with faintness, vomiting, and 
collapse, the abdomen being distended and extremely tender: the 
pulse fails, the face becomes pinched, the eyes sunken, and the 
extremities cold, and copious perspiration breaks out, death occur- 
ring usually in from twelve to forty-eight hours. 

Management. — The diet of a patient suffering from gastric 
ulcer is of the highest importance ; solid food should be avoided, 
and cool and easily digestible fluids only allowed. If there is 



88 A MANUAL OF NURSING. 

severe pain, or hsematemesis, the feeding should be carried on by 
nutrient injections, and nothing but a little ice allowed by the 
mouth. Counter-irritation to the epigastrium often gives relief, 
and rest in bed should be insisted on in severe cases. The vomit 
should be saved, and the motions inspected for blood. 

A heavy meal, indigestible food, or exertion may cause the 
ulcerated wall of the stomach to give way, the food escaping out 
of the stomach into the peritoneum. 

"When perforation has occurred the drug administered is either 
opium or morphia to allay the pain, and soothing fomentations to 
the abdomen (see Peritonitis). 

INTESTINAL COLIC— Symptoms.— The pain is of a griping 
character, and is situated in the bowels. The common cause is 
constipation and flatulence, or the presence of some indigestible 
material in the intestines. The pain is relieved by pressure and 
warmth, and after an aperient and free action of the bowels is 
removed. The temperature is not usually raised unless there is 
some further complication. Intestinal colic may be a symptom in 
obstruction of the bowels, or inflammation of the caecum. 

Management. — The safest method of acting on the bowels in 
all doubtful cases is to make use of enemata, since aperients in- 
crease the pain, and aggravate the symptoms in unsuitable cases. 

HEPATIC or GALL-STONE COLIC is due to the presence 
of a gall-stone in the bile duct. 

Symptoms. — The agony may be intense during the attack, 
the sufferer lying curled up or rolling over with the pain ; there 
is often faintness, vomiting, and profuse perspiration when the 
pain is at its worst. The pain extends over the upper part of the 
right side of the abdomen and down to the navel. The attack 
may subside suddenly, and may be followed by jaundice, which 
usually occurs when the stone obstructs the bile duct. 

Management. — The best relief in gall-stone colic is obtained 
by the hypodermic injection of morphia, or by opiates ; hot 
fomentations sprinkled with laudanum, or a hot bath will assist in 
alleviating the pain. In cases of suspected gall-stones the motions 
should be examined for stones, and for this purpose it may be 
necessary to break up the evacuations and pass them through a sieve. 

The common gall-stones vary greatly in size, are of dark brown 
or black colour, and are marked with facets when there are 
several, as is usually the case ; more rarely they are single and 
crystalline. 

PERITONITIS. — The peritoneum, or delicate membrane 
covering the outer surface of the bowels, is liable to inflammation, 



DISEASES OF THE DIGESTIVE SYSTEM. 89 

as the result of cold or an injury, or it may arise as a complication 
in puerperal fever, typhoid fever, or other bowel complaints, or 
from perforation of the stomach or bowels. 

Symptoms. — Simple peritonitis is usually attended with fever, 
abdominal pain, vomiting, and constipation. The pain varies in 
severity, is more or less general over the abdomen, and is accom- 
panied by much tenderness on pressure. Most patients recover 
in the simple forms, but the severe cases are dangerous, and 
the patient lies on the back with the knees drawn up, and 
apprehensive of the least pressure, even of the bed-clothes. 
Distension of the abdomen occurs after a time, and pain in 
micturition or after any movement is complained of. The 
tongue may be red with a tendency to dryness, and there is con- 
siderable thirst. The face looks drawn, the eyes sunken, the 
tongue brown, and crusts collect on the lips. Death may be 
preceded by delirium, and is often sudden. 

Management. — Great care is required in moving patients 
suffering from peritonitis, the bed-pan should always be used, and 
getting out or sitting up in bed should be forbidden. The 
pressure of the bed-clothes may be kept off the abdomen by a 
cradle, and any applications such as poultices, bran-bags, or 
fomentations should be made as light as possible. 

The vomiting may be allayed by ice, and nourishment should 
be given in a fluid form in small quantities. Purgatives are 
injurious in the majority of cases, and opium or morphia is 
usually administered in order to keep the bowels at rest, and to 
allay pain, large quantities of these drugs being well borne. 
Stimulants will be required in cases accompanied by much ex- 
haustion. In women careful inquiry should be made with regard 
to the catamenia or vaginal discharges, as the peritonitis may be 
associated with disease of the reproductive organs. 

TYPHLITIS, or inflammation of the caecum or vermiform 
appendix, is frequently attended with some local peritonitis in the 
right flank. 

Symptoms. — Pain in the abdomen with constipation and 
vomiting are the leading symptoms, and the temperature may be 
raised, though it is often normal. 

The bowel may be loaded, and there is pain and tenderness in 
the right side of the lower part of the abdomen. 

Management. — The bowels are often very obstinate, but no 
purgatives should be allowed except under the express directions 
of the medical attendant. Enemata are useful, either of oil or 
simple, and should be given carefully and slowly, the result being 



90 A MANUAL OF NURSING. 

noted. In other respects these cases require the same manage- 
ment as in peritonitis (see Peritonitis). Perforation is some- 
times a fatal complication, or an abscess may form in connection 
with the caecum and burst into the bowel, matter being discharged 
with the evacuations. 

INTESTINAL OBSTRUCTION.— Acute obstruction of the 
bowels is a most formidable and fatal malady. In addition to the 
strangulation of the bowel in hernia, there are other causes of 
obstruction inside the abdomen (see Hernia). 

Symptoms. — As in strangulated hernia, obstinate and more or 
less complete constipation is present, and after a time vomiting 
supervenes. The abdomen becomes distended to a varying extent, 
and pain is often felt round the navel. The sickness increases, the 
vomited matter soon becomes bilious, dark brown, offensive, and 
afterwards of faecnlent odour. In a few days or more, if no relief 
is obtained, the patient dies from exhaustion. 

Management. — The administration of enemata of various kinds 
is often undertaken by the surgeon himself in these cases, and the 
long rectal tube may have to be used. If left to the nurse she 
should understand the importance of giving the enema in a 
thorough manner (see Enema, §c). The nurse should notice if 
the fluid is returned immediately or how long retained, and 
whether it is coloured by faecal matter, or if there are any hard 
lumps or other substances. If there is any result the fluid should 
be saved for inspection. The amount of urine is often diminished 
in these cases ; in some to a very great extent. The temperature 
of the body should be ascertained, but it is commonly at or about 
normal. Vomiting and hiccough are very distressing symptoms, 
and can only be allayed by ice, small quantities of fluid only being 
given to allay thirst and dryness of the mouth, while rectal ali- 
mentation may have to be employed to keep up the strength. 
The vomiting often appears to be allayed in these cases after 
opium has been given, or after the amount of fluid taken has been 
greatly reduced, but returns again if the amount of nourishment 
is increased. The abdominal distension may be partially relieved 
by hot applications or turpentine stupes. Purgatives are usually 
avoided, and should not be given by the nurse except under 
special medical direction. In the more favourable cases the 
bowels are relieved after a time, and the vomiting ceases, and the 
patient recovers. In others, the operation of abdominal section is 
performed in the hope of finding and removing the obstruction to 
the bowel. 

Chronic Obstruction of the Boicels. — The symptoms are much 



DISEASES OF THE DIGESTIVE SYSTEM. 91 

the same as in the acute form, but of less immediate urgency. In 
some cases due to cancer of the bowel or the pressure of tumours 
from without, the obstruction is not complete, and the motions 
are small and constipated, and perhaps contain blood or mucus. 
The case may extend over a considerable period, with intervals of 
partial or temporary improvement. In others, the amount of 
vomiting is not great, but the bowels cease to act, no motion 
being passed for a month or even more, without any great dis- 
tension of the abdomen. 

DIARRHOEA is a symptom of irritation or disease of the in- 
testines, and consists in frequent and urgent calls to relieve the 
bowels, the evacuations being for the most part of a liquid 
character. 

The causes of simple diarrhoea are various, the commonest being 
unsuitable or indigestible food, cold, and epidemic influences; con- 
stipation is also a frequent source of diarrhoea, owing to the irritation 
of the intestine by the hard lumps. The bowels may be merely 
relaxed, or there may be copious purging with griping pain and 
constitutional disturbance. 

ENGLISH CHOLERA, or SUMMER DIARRHCEA, may pre- 
vail during the summer and autumnal season, and is sometimes 
epidemic or coincident with infantile diarrhoea. 

Symptoms. — It is characterised by severe pain and cramps in 
the abdomen, vomiting, profuse purging, and attended by collapse 
indicated by drawn and pinched features, sunken eyes, coldness 
of the extremities, feeble pulse, and altered voice. The symptoms 
have a close resemblance to Asiatic cholera, but are less sudden 
and severe, and the motions contain some bile, being often of a 
greenish colour (see Cholera, Infantile Diarrhoea). 

Diarrhoea is an important symptom in typhoid, dysentery, 
tubercular and other forms of ulceration of the bowels. 

Management. — Motions. — The nurse should notice the character 
of the motions in alb cases of diarrhoea, whether watery, or of thick 
fluid consistence, or if the fluid is mixed with hard lumps or 
" scybala "; whether frothy or yeast-like, indicating fermentation, 
or if containing slime or mucus as in dysenteric affections. The 
colour and odour are also of importance. 

Melsena. — Black stools may be caused by the presence of blood 
which has been altered in colour by the action of the gastric 
juices, unless the blood comes from the lower part of the large 
bowel, in which case it may be bright red. Melaena is often 
significant of ulceration of some part of the alimentary canal (see 



92 A MANUAL OF NURSING. 

Gastric Ulcer). It should be remembered that some medicines 
such as bismuth and iron give a dark colour to the evacuations. 

Management. — Simple diarrhoea due to constipation and in- 
digestible material may be relieved by a dose of castor oil or some 
simple aperient, or if the diarrhoea continue after the aperient has 
acted some form of chalk mixture is useful. Continued or severe 
forms of diarrhoea, perhaps indicating typhoid or some ulcerative 
condition of the bowel, should not be neglected, and medical 
advice should be sought. In the meantime warmth may be 
applied to the feet and abdomen by means of fomentations and 
bran-bags, and the patient should be advised to remain lying 
down. 

Diet. — Partial or complete abstinence from food is essential for 
a time, and subsequent limitation to a simple dietary of milk, 
arrow-root, cornflour, biscuits, or farinaceous puddings. 

In acute cases iced water, barley water, or brandy may be 
administered. 

Persons subject to attacks of diarrhoea should avoid partaking 
in hot weather of much fruit, vegetables, sweets, pastries, or 
indigestible material. 

In chronic diarrhoea beef-tea is injurious, but meat juice, raw 
meat, or pounded meat can often be taken instead (see Infantile 
Diarrhoea). 

THE STOOLS— Examination of the stools or faeces.— 

The following points should be noticed : — 

Consistence. — Solid and natural, small rounded masses (scybala), 
semi-solid, loose, slimy, fluid, watery. 

Amount. — Scanty or copious. 

Colour. — Dark brown and natural, bright yellow, drab, putty 
colour, white, greenish, black. 

Odour. — If peculiar or highly offensive. 

Constituents. — Undigested food, grape-skins, currants seeds, 
fruit-stones, &c. 

Foreign Bodies accidentally swallowed. 

Intestinal Worms. — (See Worms.) 

False Membranes — Shreds, or casts of mucous membrane. 

Gall-stones and biliary concretions. Search for gall-stones 
should be made by breaking up the motion in water and straining 
through muslin. 



CHAPTER VII. 

Diseases of the Skin and Kidney. 

Skin— Structure — Sweat Glands— Sebaceous Glands— Nails and 
Hair— Corns and Warts — Erythema— Nettle-Rash — Petechia— 
Psoriasis — Pigmentation — Management of Eczema— Herpes or 
Shingles — N^evus — Pediculi or Lice — Scabies or Itch — Tinea or 
E ingworm — Chloasma. 

Kidney— Structure — Ureters — Bladder — Examination of the Urine 
— Deposits — Suppression of Urine — Symptoms and Management 
of Bright's Disease, Acute and Chronic — Albuminuria — Renal 
Colic — Diabetes— Tests for Sugar— Dietary for Diabetics. 

Structure of the Skin. 

THE SKIN. — The outer or superficial layer of the skin is 
composed of scales, which are constantly being rubbed off in the 
shape of fine white dust, and as constantly reproduced from the 
deeper layers. These scales or epithelium may be shaved off or 
rubbed off without causing bleeding, and it is this layer which is 
raised by a blister: it is called the cuticle. 

The deeper layer, the cutis, or true skin, contains numerous 
small blood-vessels, and fine nerve fibres enclosed in connective 
tissue. The surface is raised into ridges, and has countless 
minute projections called papillae, containing the nerve endings, 
which impart to it its delicate sense of touch ; and its readiness to 
bleed is owing to the very free supply of capillary blood-vessels. 

The skin not only acts as a covering to the body, but it is also 
an organ of excretion, and contains glands which serve this purpose, 
namely, the sweat glands and the sebaceous glands. 

The Sweat Glands consist of little tubes opening into the 
surface of the skin, and having their ends coiled up in the deeper 
parts. Water and sundry impurities are extracted from the 
blood and poured on to the surface of the skin in the form of 
sweat. 

The Sebaceous Glands supply a fatty or oily fluid which 
lubricates the skin. 

Nails and Hair are modifications of the superficial layer of the 
skin. The nails are formed of scales arranged in compact layers 



94 



A MANUAL OF NURSING. 



containing horny material to which the hardness is due. The hair 
arises from a root imbedded in the deeper layer of the true skin, 

and has a superficial 
scaly outside and a 
central pith. It con- 
tains pigment which 
gives the hair its special 
colour. 

Diseases of the Skin. 

CORNS and WARTS 

are little tumours of 
the skin, and are formed 
by outgrowth and en- 
largement of its natural 
papillae, with an increase 
and thickening of the 
cuticle. They may oc- 
cur on almost any part 
of the body ; a favourite 
situation being the hand 
where they are apt to 
grow in large numbers. 
They bleed easily if 
wounded, but are merely 
a disfigurement. They 
sometimes disappear of their own accord, or they may be destroyed 
by acetic acid or some other form of caustic. Their growth is 
increased by dirt and occupations giving rise to irritation of the 
skin. 




Fig. 41. — Section of Skin (magnified), showing 
Hair with Sebaceous Glands, and Sweat Glands. 



ERYTHEMA is the name given to an inflammatory redness of 
the skin which may be local or general. Local erythema is well 
exemplified in an ordinary chillblain, and in addition to the red- 
ness there is often swelling, heat, and itching. A similar condition 
may be produced on any part of the body by an irritant, new 
flannel, acid secretions, counter-irritants, &c. 

General or constitutional erythema, or rose rash, may appear on 
the body, as the result of a chill during perspiration, or from 
dyspepsia, and is liable to attack persons of a rheumatic tempera- 
ment. 

The form of erythema common in rheumatism takes the shape 
of large raised oval patches, situated usually over the shin or fore- 



DISEASES OF THE SKIN AND KIDNEY. 95 

arm, which are tender to the touch. The colour changes to purple 
or violet, and fades into a yellow tint before disappearing. This 
same form is frequently seen in young women associated with the 
catamenia. 

In the local forms of erythema the source of irritation should 
be ascertained and removed, when the rash will probably subside; 
the pricking and itching may be allayed by cooling lotions. The 
constitutional form requires suitable treatment if due to rheumatism 
or any special taint. The simple affection from dyspepsia or chill 
may be treated by saline aperients and the warm bath. The close 
resemblance of the rash to scarlatina, or in some cases to measles, 
should be remembered. 

URTICARIA or NETTLE-RASH.— The appearance of the 
rash is similar to that produced by the sting of a nettle, namely, a 
white wheal on a red ground. The itching is intolerable, and the 
rash may be local or scattered in patches over the body. There is 
not usually much constitutional disturbance, sore throat, or affection 
of the air passages, though the rash may appear on the palate and 
fauces. Common causes of urticaria are — irritation of the skin, 
strong mental emotion, indigestible food, shell-fish, and various 
drugs. 

The itching may be allayed by the application of equal parts of 
tincture of benzoin and water. 

PETECHIA is the name given to small points of haemorrhage 
under the skin, which leave a red stain not obliterated by pressure 
of the finger. They are common as the result of flea-bites, and in 
such diseases as scurvy, purpura, and rheumatism. 

PSORIASIS is a scaly eruption, commonly found in its simple 
form about the elbows, knees, or other parts of the body. The 
scales are of silvery white colour, heaped up on patches of reddish 
colour on the surface of the skin, varying in size from a sixpence 
to a two shilling piece. 

PIGMENTATION of the skin may be the result of using 
certain ointments or of psoriasis. It is not uncommon in cata- 
menial disorders. In Addison's Disease it is a symptom of the first 
importance, the common situations being about the neck, axilla?, 
mamma, navel, thighs, bend of the knees and elbows ; at the 
garter below the knee, and about the female genitals. 

ECZEMA may be either acute or chronic. There is inflamma- 
tion of the skin, and an eruption presenting a variable appearance. 
It may be papular, vesicular, j^ustular, or a combination of all, but 
its most characteristic appearance is that of a raw moist surface 



96 A MANUAL OF NURSING. 

more or less covered with crusts, and known as moist or weeping 
eczema. The fluid is derived from the broken vesicles, and the 
crusts are formed by the dried exudation, and the epidermal scales 
which have been shed, and adhere to the sticky discharge. In 
the dry form of eczema, this moisture is absent, and there are red 
dry patches covered with thin scales. 

The acute form is attended with some degree of constitutional 
disturbance, and there is much redness and swelling of the skin, 
and a large area may be attacked. 

Soreness and itching accompany the different forms of eczema, 
and other discomforts according to the part of the body attacked. 
It is a very common disorder in children and infants, attacking 
the scalp (eczema capitis), and causing enlarged glands in the neck ; 
or it appears behind the ears, or in the folds of the skin about the 
neck, or in the creases about the thighs and genital organs. 

In adults it may attack any part of the skin, but is common 
about the forehead, nostrils, auditory canal, scrotum, breasts, palms 
of the hands, and soles of the feet. 

The causes of eczema are numerous, some constitutional, others 
local; for the latter search should be made for some cause of irri- 
tation, common examples being dirt, friction, lice, and other para- 
sites, and in babies the constant wetting of the unchanged napkins. 

Management. — After the irritating material has been discovered 
and removed, the attention should be directed towards the local 
treatment which should be applied in a systematic manner. It is 
useless to smear ointments over the thick scabs, or on the matted 
hair covering the raw surfaces, and expect them to heal. The 
following directions given by Dr Liveing should be observed : — 

1st. To remove the crusts : lubricate well with oil or apply rags 
thoroughly soaked in oil for an hour or two ; then use a hot bread 
and water poultice. If the scabs are hard, the poultice may be 
left on for several hours. "When the crusts are softened, they 
should be removed with the finger-nail or a piece of card, and any 
hairs attached to them cut with scissors. The parts affected 
should be then well cleaned with weak gruel, yolk of egg, or soft 
soap and water. Soft or potash soap is best applied by dipping a 
piece of flannel in warm water, laying a portion of soap upon it, 
and then rubbing the part well until a good lather is formed. 

2nd. Ointments should not, as a rule, be merely rubbed on the 
eczematous surface, but applied carefully on strips of linen rag, 
which should be changed at least once in every twelve hours, and 
kept in position by a bandage, night-cap, or strapping, and the air 
excluded. The stronger ointments should be simply rubbed in 
with the finger. 



DISEASES OF THE SKIN AND KIDNEY. 97 

Lotions should generally be applied on linen rag thoroughly 
soaked and covered with oil-silk, and should never be allowed to 
get dry. 

Tars and oils may be applied with a brush, but all tars must be 
used with caution, and only small portions of diseased surface 
treated at a time to test its effect. 

In all cases of eczema the ordinary washing with water or soap 
must be forbidden, especially in the later stages. Frequent dusting 
with starch powder and moderate friction may be substituted for 
washing, or fine oatmeal may be used with a little soft water. 
The friction of flannel or scratching must be avoided, and children 
should wear soft gloves, or have their hands tied up at night to 
prevent this source of irritation. 

HERPES is a vesicular eruption; the vesicles appear in 
groups, and the contents rapidly become milky, drying up, and 
forming scabs. There are several forms of this complaint, the 
two commonest being Herpes labialis and Herpes zoster or 
Shingles. 

Herpes labialis is apt to accompany attacks of inflammation of 
the lung, and occurs about the lips and sides of the nose; a little 
poultice and zinc ointment is all that is necessary for its local 
treatment. 

Herpes zoster, or Shingles, is often preceded by severe 
neuralgic pain round one side of the chest, with perhaps some 
constitutional symptoms. After a time the vesicles of herpes 
appear over the painful area, and extend from the spine round the 
side of the chest to the sternum. It is almost always confined to 
one side of the chest, and a second attack is unusual. The pain 
may continue with considerable severity for some time after the 
eruption has disappeared. 

During the eruption the vesicles may be painted over with 
flexile collodion or smeared with carbolised oil. 

N2EVTJS is the name given to the various port-wine marks, 
red stains, and small red tumours consisting of dilated capillaries. 
These small naevus tumours are very common in children, and 
are only of consequence from producing disfigurement in exposed 
situations. Surgical treatment is then called for, and is most 
suitable and best done when the child is young. A common 
practice is to pass hare-lip needles through the base, and then 
constrict the tumour by a thread tightly tied round, until the 
tumour after a time sloughs off. Dressings should be applied 
afterwards, and care taken after the operation to avoid friction or 
sudden tearing off of the tumour. 



98 A MANUAL OF NURSING. 

ANIMAL PAEASITES — PEDICTTLL— Lice frequent the 
human body, especially in the case of the unwashed, and produce 
an eruption of slightly raised papules accompanied by much 
itching. There are three varieties, one affects the hair of the 
head, another the hair of the pubes and armpits, the third the 
body. The animals have the appearance of little crabs, and may 
be easily seen, if carefully searched for, by the naked eye, or a 
magnifying glass. In the head their existence is shown by their 
eggs, like small white beads sticking to the sides of the shafts of 
the hairs ; the eggs are called nits and the lice pediculi, the 
latter may be found secreted under the hair, especially at the back 
of the head and nape of the neck. 

The second form inhabits the small hairs on the body, armpits, 
and pubic region. 

The body lice are more difficult to find ; they live in the folds 
and creases of the under garments, where they should be searched 
for. The two latter forms infest mainly adults of both sexes. 
The head lice also attack children, and produce eruptions of 
varying character and severity about the scalp and neck, with 
scabs and enlargement of the glands. 

Management. — One of the most unpleasant duties of the 
hospital nurse is attending to the hair of the poor and un- 
clean. The head should always be examined, and if the nits are 
seen on the hairs the presence of lice is a certainty, and special 
ablutions will be required. 

It will often be necessary first of all to remove a good deal of 
hair, and then after soaking and combing out with a warm 
solution of carbolic acid and water (1-60), the head should be 
washed in abundant soap and water. The clothes must also be 
removed and disinfected or baked. 

White precipitate ointment or chloroform will kill the pediculi, 
but in cases of children with sore heads mercurial ointments 
should only be used under medical advice. 

SCABIES, or THE ITCH, is a contagious disease of the skin, due 
to a small parasite which burrows in the skin and sets up irritation. 
A vesicle is formed which causes great itching, with inflammation 
of the skin, and pustules often form and break, causing scabs. 

The parts of the body most frequently attacked are the fingers 
and toes, wrists, armpits, thighs, and abdomen, but it often 
becomes general, with the exception of the face, which usually 
escapes. Children are very liable to the disease, and convey it to 
one another by sleeping together. 

Management. — The whole body should be thoroughly washed 



DISEASES OF THE SKIN AND KIDNEY. 99 

in warm soap and water, and the patient should take a warm bath, 
and soak in it for an hour. TVnen thoroughly dry, the skin over 
the whole body, except the head and face, should be treated with 
sulphur ointment. The strength of the ointment must be adapted 
somewhat to the particular case. For adults with thick skin the 
pharmacopceial ointment of sulphur may be used. 

For children, or individuals with delicate skins, or where there 
is much inflammation or eczema, a weaker ointment or one diluted 
with equal parts of vaseline should be first used. The ointment 
in all cases should be thoroughly rubbed into every part at bed- 
time, and a long nightdress with gloves and socks should be 
afterwards put on, and the person should remain in bed for ten or 
twelve hours. A warm bath may be taken in the morning, and 
the same process repeated the next and following night. If the 
ointment has been thoroughly rubbed in, two or three applications 
are commonly sufficient. 

Eczema may be produced by the sulphur, and in most cases 
some eruption remains for a time after the itch mite has been 
destroyed, and may be alleviated by the use of vaseline or some 
simple ointment. The clothes and underclothing of those affected 
should be baked to a temperature of 200° F., or fumigated with 
sulphur, and in families the children should be carefully isolated. 

Vegetable Parasites, 

TINEA TONSURANS, or RINGWORM, is a contagious and 
parasitic affection which appears in two forms ; one, common in 
children, attacks the hairy scalp, the other attacks the skin of the 
body. 

Ringworm of the scalp commences with faint red, circular, 
scurfy patches having a tendency to itch, and on close observation 
the hairs are noticed to be short and easily broken. The roots 
of the broken hairs under the microscope show the minute spores 
of the fungus, and the fibres of the hair are seen to split up. 

Ringworm of the body takes the form of circles or fairy rings 
with slightly elevated red margins, and the surface is covered 
with fine dry scurf. 

The patches increase in size and multiply, and are attended 
with itching. 

Management. — This consists in destroying the parasite, and is 
a simple matter in ringworm of the body. The patches may ba 
painted with acetic acid or sulphurous acid, or white precipitate 
ointment may be used. 

Ringworm of the scalp is far more obstinate than ringworm of 



100 



A MANUAL OF NURSING. 



the body, especially in long-standing cases. The hair should first 
of all be cut quite close for an inch round each patch, and strong 
acetic acid or mercurial ointment well rubbed in at night, and 
washed off with soap and water in the morning ; during the day- 
time a lotion of sulphurous acid may be applied on lint, and 
covered with oil-silk. Careful and constant applications may cure 
the disease in a few months, if taken at the commencement. In 
long-standing cases the patches may be painted with Coster's 
paste or dilute citrine ointment. 

In children the general health often requires attention, and 
they should be kept from school on account of the contagiousness 
of the disease. 

CHLOASMA is another parasitic disease, showing itself in fawn- 
coloured patches, covered with fine scurf, most commonly on the 
chest, back, or abdomen. It may be removed by vigorous friction 
every day with flannel, soap and water, and sponging with sul- 
phurous acid lotion. 

Tlie Kidneys. 

THE KIDNEYS (fig. 42) are two in number, of the shape of a 

French bean, measuring about 
four inches long by two inches 
across, and situated one in each 
loin below the level of the ribs. 
They are of reddish-brown colour, 
glandular in structure, and may 
be compared to the skin in pos- 
sessing numbers of tubes like 
the sweat glands, surrounded by 
small capillary blood - vessels. 
The function of these tubes is 
to separate the constituents of 
the urine from the blood, in a 
fluid form, the fluid being col- 
lected into a special part of the 
kidney, into which opens a duct 
called the ureter. The ureters 
are long tubes which descend one 
from each kidney in the hinder 
part of the abdomen, and finally 
open below into the bladder. 
The Bladder forms a bag or 




1. Kidney. 

2. Ureter. 



Fig. 42. 

3. Renal Vessels. 

4. Bladder. 



reservoir, and is situated in the 



pelvis in front of the rectum. It receives the urine drop by drop 



DISEASES OF THE SKIN AND KIDNEY. 101 

from the ureters, and when full it is emptied. If the bladder is 
fully distended, it forms a rounded swelling in front of the lower 
part of the abdomen, between the navel and the pub 

The function of the kidneys is to purify the blood of waste 
substances and water, many of which, if retained, act as poisons. 

EXAMINATION OF THE URINE.— The amount and quality 
of the urine are the main guides to the detection of the various 
diseases of the kidney and bladder, and it is important for the 
nurse to be acquainted with the condition of the urine in health 
(see Bladder, Retention of Urine), 

The quantity passed in the twenty-four hours should average 
from two to three pints, and most healthy adults do not as a rule 
require to pass water after going to bed at night until rising in 
the morning. 

The urine in health should be transparent and clear when 
passed, but after standing there may be a faint cloud of mucus 
at the bottom of the vessel. 

Tested by blue litmus-paper there is a slight change to a red 
tint, showing the reaction to be acid. 

The specific gravity, taken by the urinometer, varies from 1015 
to 1020. 

There are many deviations from the normal standard without 
any actual disease of the kidney being present; thus a temporary 
increase in the quantity of the urine, light colour, and low specific 
gravity may be due to excitement, cold weather, or hysteria. A 
temporary diminution in the amount of the urine, high colour, 
increased specific gravity, and cloudiness after standing is common, 
occurring in hot weather, and in feverish conditions. 

Deposits in the urine are often the result of dyspepsia, gout, 
and bladder troubles ; or are due to disease of the urethral passages, 
or to vaginal discharges in females. Common deposits are — urates, 
phosphates, uric acid, mucus, and pus. 

Urates usually form a deposit of reddish-brown or brick-red 
colour in considerable quantity in concentrated urine on becoming 
cool. If placed in a test-tube and warmed they gradually dis- 
appear and the urine becomes clear. 

Phosphates may form a deposit in alkaline urine; when boiled 
the turbidity or cloud is increased, but disappears on adding a few 
drops of acetic or nitric acid. 

Uric Acid may be deposited as a fine red sand at the bottom of 
the glass, or may adhere to the sides, or form a ring at the surface 
of the urine ; the urine is commonly very acid. 

Mucus and Pus. — The former gives rise to a flocculent or 



102 A MANUAL OF NURSING. 

cloudy deposit of whitish colour. The latter is thick, heavy, and 
of whitish, greenish, or yellowish colour. The reaction of the 
urine is usually alkaline, and it does not clear up on boiling or 
adding acid. 

The normal colour of the urine may be altered by the presence 
of blood or bile. 

Hcematuria. Blood in small quantities gives a smoky tinge, in 
larger quantities a red, scarlet, or bright red hue is present, or it 
may appear as dark brown or porter coloured. When intimately 
mixed with the urine the blood commonly comes from the kidney, 
when passed in clots, or by itself before or after micturition, its 
source is probably the urethra or bladder. 

Bile imparts a yellow, golden, greenish, or dark olive colour to 
the urine, and is associated with jaundice; when spilt on the 
clothes it gives a yellowish stain. The amount of bile in the urine 
in a case of jaundice may vary considerably in the twenty-four hours. 

Suppression of Urine is a symptom of considerable danger, and 
may indicate a failure on the part of the organs to excrete the 
urine. Suppression may occur in acute kidney disease, or in 
cholera and some other bowel affections, and must be distinguished 
from retention of urine, in which the bladder is full or contains 
urine, but there is some impediment to its being discharged from 
the bladder (see Retention of Urine), 

Diseases of the Kidneys. 

BRIGHT'S DISEASE, or INFLAMMATION OF THE 
KIDNEY. — Acute Bright's disease is brought on by exposure to 
cold, scarlatina, and some other acute affections, or it may occur 
in pregnancy. 

Symptoms. — In the severer cases the onset may be sudden, with 
fever, marked chilliness, vomiting, headache, pain in the loins, and 
gastric disturbance. The urine is scanty, or may be temporarily 
suppressed, and what is passed is turbid or high coloured, or mixed 
with blood. The eyelids and face are soon noticed to be puffy, 
also the skin about the ankles, genital organs, and the dependent 
parts of the body. The skin has a whitish, waxy appearance, and 
readily pits on pressure. The vomiting may be troublesome, and 
the pain in the loins severe ; and in unfavourable cases complica- 
tions may occur — dyspnoea from oedema of the larynx or lungs ; 
or inflammation of various organs, the lungs, pleura or peri- 
cardium ; or coma and convulsions may set in. In a large number 
of cases the onset is mild or insidious, and the condition of the 
urine is the most marked feature. 



DISEASES OF THE SKIN AND KIDNEY. 103 

Albuminuria. — The urine should be saved for examination in 
all cases where there is any suspicion of the disease, or where it is 
known to be likely to supervene, as after scarlatina or diphtheria. 

Test for Albumen. — On boiling the urine, a more or less thick 
cloud of deposit appears, which is not dissolved but is rather in- 
creased by adding a few drops of acetic acid. 

Management. — In all cases of acute Bright's disease the patient 
should be kept in bed, and a flannel nightdress may be worn with 
advantage in cold weather. The condition of the bowels, skin, 
and the urine requires attention, and the diet is of the highest 
importance. Free action of the bowels is desirable, and active 
purging may be necessary in some cases. 

Perspiration should be encouraged, and free action of the skin 
promoted by warm or hot bottles, the wet pack, or preferably the 
vapour bath (see Baths). The urine should be saved, and the 
quantity passed in the twenty-four hours measured and recorded 
on a chart kept for the purpose. The patient should be directed 
to pass water before the bowels act, and after all the urine has 
been collected together and measured a specimen may be set apart 
in a urine glass, or if desired one specimen of the day and another 
of the night may be arranged separately. The conical specimen 
glass should be used in order that the deposit may be collected at 
the bottom, and obtained for microscopical purposes. 

Diet. — Many physicians allow only milk and bland drinks, such 
as barley water or rice water, throughout the attack, and for a con- 
siderable period afterwards. If albumen appear in the urine of a 
patient convalescent from scarlatina, the nitrogenous food should 
be discontinued, and milk and farinaceous food substituted. A 
plentiful supply of fluids assists the action of the kidneys, and a 
more copious flow of urine is promoted. During convalescence 
there is often great pallor and debility, and care should be taken 
on first going out to avoid cold winds and wet. Alcohol is seldom 
beneficial, and in returning to a more liberal diet the urine should 
be examined at intervals for albumen, and the state of the bowels 
regulated. 

CHRONIC BRIGHT'S DISEASE.— There are two forms of 
this disease which are very different in appearance and symptoms. 
The one is more liable to attack persons in the first half period of 
life, either commencing insidiously or following on the acute form. 

The Symptoms may be said to correspond very much with 
those of the acute disease, but it runs a slow course, showing a 
special tendency to produce anaemia, dropsy, vomiting, and gastric 
troubles. The other is decidedly a disease of more advanced life, 



104 A MANUAL OF NURSING. 

commencing usually over forty, and is commonly the result of over 
indulgence in alcohol, or over-work. The term granular or gouty 
kidney is sometimes applied to this form of the disease, and its 
symptoms are, loss of nutrition, giddiness, and headache, shortness 
of breath, and copious micturition, especially at night ; the urine 
being light in colour, and of low specific gravity. Attacks of 
gout may be associated with the disease, but dropsy is not 
common in the early stages. Death may occur from dyspnoea, 
cerebral haemorrhage, uraemic convulsions and coma, or from 
exhaustion. 

Management. — The same rules as in the acute form will apply 
to the clothing, but except dropsy is present or other serious com- 
plications the patient is not always confined to bed. The urine 
should be measured, and specimens saved for examination, and 
the effect of remedies on the amount of the urine will have to be 
observed and noted. The condition of the skin, and the encourage- 
ment of perspiration by vapour baths is important. This latter is 
the most efficient means of diminishing the dropsy, and may have 
to be carried out by the nurse for a considerable period (see Baths). 

Flannel should be worn from head to foot next the skin, and the 
feet especially should be kept warm and dry by woollen stockings. 
Warm baths, or Turkish baths, during convalescence, and moderate 
exercise help to promote the action of the skin. 

The severe complications of excessive dropsy, dyspnoea, and 
lung affections, or uraemic coma and convulsions are commonly 
fatal (see Management of Dropsy, Dyspnoea, Coma, Convulsions). 

Diet. — Milk is the chief article of diet, but greater freedom has 
to be allowed in many cases where the milk is badly taken or does 
not agree. Four to eight pints may be taken in the twenty-four 
hours, when nothing else is allowed ; or with less quantity, nutri- 
tive broths, fat meats, such as bacon or pork, fish and white meat 
may be substituted ; rice and green vegetables are also permissible. 
Potatoes, eggs, and much butcher's meat should be avoided. Head- 
ache, palpitation, or indigestion are signs that the diet is unsuitable. 

RENAL COLIC, or pain in the kidney, is usually the result of 
a stone in the kidney or ureter. The pain is felt in the loin of 
the side affected, working its way round to the abdomen and flank, 
and perhaps extending down the thigh and towards the genital 
organs. The pain varies from a dull ache to an acute almost 
unbearable paroxysm, during which the thigh is flexed to relax 
the abdominal wall; the patient is sick, or has a rigor, and 
becomes faint, breaking out into a profuse sweat. The urine may 
be retained, or there may be a constant desire to micturate, only a 



DISEASES OF THE SKIN AND KIDNEY. 105 

small quantity being passed at a time ; it often contains blood, or 
a deposit of various crystalline forms. 

Management. — During the attack, hot applications to the 
affected part sprinkled with laudanum help to relieve the pain and 
spasm, or the hot bath gradually raised to as high a temperature 
as can be borne is useful, the patient remaining in during the 
intensity of the attack. The length of the attack varies from a 
few to many hours, and in many cases relief is only obtained by 
the use of morphia given hypodermically. The urine should 
always be carefully saved, as the presence of blood or crystalline 
deposit is of much assistance in determining the nature of the 
complaint. 

DIABETES. — Although not a disease of the kidney, the urine 
in this complaint is altered in character by the presence in it of 
sugar. 

When describing the assimilation of the different food-stuffs in 
digestion, the easy absorption of sugar by the blood, and the 
transformation of all starchy material into sugar by the salivary 
juice was mentioned. The amount of sugar passing into the 
general circulation in health would be very great, were it not for a 
special function of the liver to prevent a considerable quantity 
from doing so. When this function of the liver is at fault, or in 
some way deranged, the sugar is discharged with the blood circu- 
lating in the body, and finds an outlet through the kidney. The 
urine in diabetes contains sugar in varying amount, and the com- 
plaint is attended in addition with other symptoms of importance. 

Symptoms. — The onset is mostly insidious, and commences 
with an increase in the quantity of urine, the patient having to 
get out of bed once or more often during the night. The appetite 
may be increased, but loss of weight and muscular weakness are 
noticed, and thirst and dryness of the skin are complained of, 
while the urine, on examination, is found to contain sugar. 

Urine in Diabetes. — The quantity is much increased, from two 
to six quarts or more is common. The colour is clear or greenish- 
yellow, and the specific gravity often marks as high as 1030-1045. 

Tests for Sugar. — The usual test for sugar is known as the 
Copper test, in which a blue solution of copper on being boiled 
with the diabetic urine changes to a yellow or orange-red colour. 
There are different ways of applying the test. Fehling's solution 
is commonly used in Hospital work ; a small quantity of this blue 
fluid is boiled in a test tube, and an equal quantity or less of the 
urine is added, and then raised to the boiling point, when the 
characteristic colour will appear, if sugar be present, in the form of 



106 



A MANUAL OF NURSING. 



a copious precipitate. Another method is to boil a small quantity 
of the urine with an equal quantity of liquor potassse, and then 
add a few drops of a dilute solution of sulphate of copper, when 
the reddish-yellow precipitate will appear on further boiling if 
sugar is present. A third method, also useful as giving an estimate 
of the amount of sugar contained in the urine, is known as the 
fermentation test. It may be applied as follows : — 

The specific gravity of the urine is first taken and recorded ; an 
ordinary medicine bottle is then partially filled with the diabetic 
urine, and a small quantity of fresh yeast added. The cork is 
inserted, a piece having been previously cut out from one side to 
permit the gas formed to escape from the bottle \ the bottle is then 
placed in a warm place or down by the fireside. Fermentation 
should be completed in twenty-four hours or less, if the yeast is 
good, and this may be determined by boiling again with the copper 
solution, when, if all the sugar has been converted, the blue colour 
will remain. 

DIABETIC CHART. 
Name. — J. B. Age 24. Occupation. — Upholsterer. 
Admitted. — June 16, 1886. 



Date. 


Urine. 


Treatment. 


Weight. 










Oz. 


Sp.Gr. 


Analysis. 
















st. lbs. 


June 17 


240 


1040 


Sugar 44 grs. ad j$i. 
Urea 1-2 %. 


Milk. Beef tea. Bread. 


7 13* 


» 18 


168 


1040 


Sugar 36 grs. ad gi. 
No albumen. 


>> » 




n 10 


192 


1042 




Diabetic diet. 




„ 20 


180 


1039 




ii 




„ 21 


192 


1036 


Sugar 36 grs. ad §i. 


j> 




„ 22 


216 


1037 




ii 




„ 23 


96 


1038 




ii 




„ 24 


104 


1041 




ii 


8 3* 


„ 25 


168 


1042 


Sugar 31 grs. ad gi. 


>> 




., 26 


168 


1038 




ii 




n 27 


144 


1038 




ft 




„ 28 


180 


1040 




„ ^. Pulv. opii. gr.£. t. d.s. 




„ 29 


180 


1038 




J> 5 ) 




30 


144 


1036 


Sugar 29 grs. ad £i. 


„ I£. Pulv. opii. gr. i. t. d.s. 




July 1 


140 


1035 




)> >> 


8 7£ 



After complete fermentation the specific gravity is again taken, 
when it will be found to have dropped several degrees. The 
difference between the specific gravity before and after fermenta- 
tion will give the number of grains of sugar contained in an ounce 
of urine. Thus, if before fermentation, a specimen has the specific 



DISEASES OF THE SKIN AND KIDNEY. 107 

gravity 1035, and after fermentation only marks 1020, it contains 
about fifteen grains of sugar in each ounce of urine. This method 
is roughly accurate, and is useful for ordinary working purposes, 
so that the nurse can estimate from time to time, and record the 
quantitative analysis of diabetic urine, giving some idea of the 
progress of any case under her charge (see Chart). 

The course of the disease is essentially chronic, more acute and 
fatal in young adults, but more favourable in persons over 40 
years of age. Danger is indicated by increase in the severity of 
the symptoms, and a large quantity of water containing much 
sugar. The fatal termination is in many cases preceded by 
drowsiness, and heavy deep breathing, gradually passing into 
coma. Other complications are — carbuncles and boils, neuralgic 
pains, pulmonary inflammation, albuminuria, and gangrenous 
inflammation of the extremities. 

Management. — Diet is the first and chief point to be attended 
to, and it is necessary to exclude all saccharine and starchy 
material which accentuate the symptoms and keep up the activity 
of the disease. Almost all kinds of animal food, flesh, fish, and 
fowl, may be consumed by the diabetic, but the cooking should be 
carefully supervised, and the cook informed upon every point in 
the serving up of made dishes, soups, &c. Soups must not be 
thickened by farinaceous matter, joints basted with flour, or 
jellies sweetened with sugar or syrup. Many vegetables are 
obnoxious, potatoes in particular, but many green vegetables may 
be allowed. Bread is injurious, and is the most difficult article of 
every day food for which to find an efficient and palatable substi- 
tute. Milk agrees well with many diabetics, but contains sugar of 
milk, so that large quantities may prove harmful. Owing to the 
great emaciation accompanying the disease, it is important that the 
diabetic should be well fed, and from the great restriction necessary 
much ingenuity is required to provide a tempting variation in the 
bill of fare from day to day. In some cases when there is great 
loathing of the restricted diet, greater latitude has to be allowed, 
as restriction is harmful. 

Dietary. — The following dietary is useful, containing most of 
the articles of food and drink that a diabetic may partake 
of-— 

Butcher's meat, poultry, game, and fish of all kinds, fresh, 
salted, and cured ; ham, bacon, smoked and cured meats. Beef 
tea, broths, and animal soups not thickened. Eggs, dressed in 
different ways. 

Cheese, cream cheese, butter, and cream. 

Substitutes for bread are almond, bran or gluten bread, or brown 



108 A MANUAL OF NURSING. 

bread thoroughly toasted, or failing these, white bread thoroughly- 
toasted. 

Vegetables — greens, spinach, turnip-tops, celery, endive, lettuce, 
water-cress, mustard and cress, and radishes. 

The following vegetables should only be taken in small quan- 
tities, and should be boiled in a large quantity of water : — 

Turnips, French beans, Brussels sprouts, cauliflower, broccoli, 
cabbage, asparagus, seakale, and vegetable marrow. 

Vinegar, oil, and pickles. 

Jelly, flavoured, but not sweetened. Savoury jelly, blanc-mange, 
custard without sugar, olives. 

For drink, tea, coffee, cocoa from nibs, dry sherry, claret, dry 
Sauterne, Burgundy, Chablis, hock, brandy and spirits, soda-water, 
Burton bitter ale. 

The following must be avoided : — 

Sugar in any form. Wheaten bread and biscuits. Eice, arrow- 
root, corn-flour, oatmeal, sago, tapioca, macaroni, vermicelli. 
Potatoes, carrots, parsnips, beet-root, peas, Spanish onions. Pastry 
and all puddings. Fruit of all kinds, fresh and preserved. Milk 
in large quantities, sweet ales, porter and stout, cider, sweet wines, 
sparkling wines, port wine, liqueurs. 

Some variations will have to be made in different instances, 
certain articles being apt to disagree with each individual. 

The nurse will have to keep a very strict watch on patients 
under her charge with regard to the diet. In hospital practice, 
many of the patients do not understand the importance of the 
restrictions, and wilfully break through the rules, and even the 
best-intentioned will sometimes covertly obtain forbidden food. 
An unexpected increase in the sugar in the urine, or an accentuation 
of the symptoms without due cause, should raise a suspicion that 
contraband articles are introduced in some way or other. 

Worry, anxiety, and over-work should be avoided as far as 
possible, and the attention of the patient should be distracted from 
the disease. Exercise and fresh air should be obtained regularly, 
but hard travelling discouraged. 

Free and regular action of the bowels is desirable, and warm 
baths will assist the action of the skin. 

Thirst may be assuaged by acid drinks, containing dilute phos- 
phoric acid, or lemon juice, and a fair quantity of fluid must be 
allowed when the thirst is excessive. 

The symptoms are controlled either partially or entirely after 
the diet has been restricted for a short time ; the amount of urine 
diminishes, as also the quantity of sugar contained. The patient 



DISEASES OF THE SKIN AND KIDNEY. 109 

gradually regains flesh and strength, and as long as the diet is 
adhered to, continues to improve, or remains stationary. 

The drugs which exert most influence in allaying the symptoms 
are — opium, codeine, or morphia, and cod-liver-oil is beneficial as a 
food. 

Dangerous or fatal complications may be preceded by an 
increase in the symptoms of thirst and emaciation, or by pulmonary 
disorders ; constipation, shortness of breath, and drowsiness may 
indicate the approach of coma; albumen in the urine is also a 
grave symptom. 

All accidents and acute diseases are excessively fatal in the 
diabetic. From the tendency to gangrene in the older patients, 
wounds of the extremities should be carefully attended to, and 
corns should not be cut with the knife, or strong caustics applied. 



SWEATY FEET.— Excessive sweating of the soles of the 
feet is a common affection amongst domestic servants. It is 
frequently associated with a most unpleasant odour, which is 
almost characteristic of the affection, and permeates all the sur- 
roundings of persons suffering from it, and even clings to the room 
which they have left. 

Management. — It may be cured by care and attention in the 
following way : — The old boots and shoes previously worn will be 
found to have an offensive odour ; the insides may be well powdered 
with boracic acid powder, or, if much tainted with the discharge, 
the lining should be removed and new cork soles introduced. A 
solution should be prepared by adding powdered boracic acid to 
a quart or more of hot water until the water ceases to dissolve it, 
and some powder remains at the bottom. This may be allowed 
to cool. Several pairs of stockings should be placed with the feet 
in the solution, and when soaked should be afterwards dried. 
The stockings are now ready for use, and should be changed 
several times in the day in bad cases. The feet of the stockings 
should be replaced in the solution after they have been worn. 
The cork soles may be also soaked in the solution, if they become 
offensive, and dried. 

The patient's feet should be washed every night, and the soles 
anointed with zinc or salicylic ointment. 



CHAPTER VIII. 

On Fevers. 

Fever — Different Forms of Fever — Infectious Fevers — Germs — 
Contagion and Infection — Isolation — Rules for Disinfection — 
Incubation and Invasion Periods. 

Symptoms and Management of Chicken-Pox — Scarlatina — Small- 
Pox — Measles — Typhus — Typhoid Fever and its Complications — 
Diphtheria — Mumps — Cholera — Rheumatic Fever — Malarial 
Fevers— Ague. 

Different Kinds of Fever. 

The word fever denotes a more or less continued elevation of 
temperature, and is said to be moderate when it does not exceed 
103°; high when it stands at 105°; and very high or hyper- 
pyrexia! when it continues above 105°. 

The course of fever has certain characteristics in different 
diseases ; it is termed continued when it runs a prolonged course 
with but little intermission ; remittent when it fluctuates every- 
day, but does not regain the normal until the disease is at an 
end ; intermittent when there is an interval of some duration in 
which the temperature remains at the normal between the periods 
of fever. Hectic denotes a remittent form of temperature common 
in affections associated with suppuration and abscess formation, 
and is usually accompanied with a pink flush on the cheeks, pallid 
face, and a profuse perspiration when the temperature descends. 

Accompanying these varieties of feverishness there is frequently 
a sense of chilliness, or a rigor when the temperature ascends, and 
a disturbance of the bodily functions, a quick pulse, increased 
rapidity of respiration, headache, lassitude, and digestive derange- 
ment. 

THE INFECTIOUS FEVERS form a separate class owing to 
the fact that they are communicable from person to person. 

Terms have been used to classify fevers such as specific or 
zymotic, according to the views held as to the nature of the 
poison. But the doctrine accepted at the present day ascribes 
these diseases to the agency of minute organisms called germs, 



ON FEVERS. Ill 

-which are exhaled from the body of the patient. These float in 
the air, mix with the dust, or are carried in water, milk, or food, 
and thus conveyed to human beings, in whom they may produce 
an outbreak of the same disease from which they originated. 

Contagion and Infection. — Contagion implies communication 
by contact with the affected person, but infection is a more 
convenient term and includes all methods through which the 
disease may be spread from person to person, whether by close 
intercourse, or at a distance, by the dissemination of small particles 
in air, water, or other media. 

There is some difference amongst the infectious fevers in the 
degree of infective powers of the emanations from the different 
parts of the body ; thus, in diphtheria, measles, and in the early 
period of scarlatina the breath is a ready means of infection. 
In small-pox, and in desquamation after scarlatina, the skin carries 
the poison, whilst in typhoid and cholera the discharges from the 
bowels are loaded with the germs of the disease. 

Precautions to be Adapted to Prevent the Spread of Infection. 

Separation and Isolation of the Sick Person. — The first thing 

to be done in the case of infectious illness is to remove the sick 
person, and isolate him completely from others. 

At the commencement of an epidemic or outbreak, and where 
the initial symptoms of illness are unpronounced, such a proceed- 
ing may not be possible until the appearance of the rash. When 
epidemic or infectious fever is prevalent, or when it has already 
attacked a household or school, measures for isolation tan often 
be taken at the earliest onset of the disease. 

A rigor or feverish symptoms may denote the onset of any 
fever ; in measles, discharge from the eyes and nose, or sneezing ; 
in scarlatina, sore throat and pain in swallowing are early signs, 
and the contagious material is active from the commencement. 
In a school or public institution the patient should be removed to 
the sick house or sanatorium, where isolation is easily managed. 
In a private house the most secluded region should be chosen, a 
room at the top of the house for the bedroom, and if possible the 
whole floor should be kept exclusively for him and for those in 
attendance on him. The rooms may be previously stripped of all 
unnecessary furniture, curtains, carpets, or woollen material likely 
to retain particles of contagious matter. Xo one else should be 
permitted to enter the room, and the inmates of the house should 
be kept from all communication. The attendants should avoid 
unnecessary intercourse with the household, and the needful 



112 A MANUAL OF NURSING. 

crockery and utensils should be kept exclusively for the patient's 
use, and instead of being sent downstairs, they should be washed 
by his attendant. The food should be placed outside the door and 
taken in by the nurse, the uneaten remnants being destroyed. 

Disinfection has for its object the destruction of the morbid 
particles or germs thrown off from the sick person. Disinfection 
is necessary for the room, the patient, and for every thing that 
has been in the same room with him. Some general rules have 
been laid down by the medical officers of health as usually 
applicable in all cases of infectious illness. 

Rules for Disinfection. 

1. The room occupied by the patient must be well ventilated, 
the windows kept partly open, and, when the season will permit, 
a fire should be kept burning in an open grate. The floor must 
be cleaned every day, and sprinkled with disinfectant fluid. 

2. The door should be closed, and a sheet, kept constantly wet 
with a solution of carbolic acid (1-40), may be hung as a curtain 
outside, so as to cover all the crevices. 

3. All bed and body linen after use and before leaving the 
room should be left to soak for at least an hour in the carbolic 
solution. These should then be boiled in water, and well exposed 
to the air. 

4. All discharges from the patient, phlegm, vomit, urine, faeces, 
should be received into vessels containing some disinfectant 
powder. After use, some more of the disinfectant should be 
added before carrying the vessel out of the room and emptying it 
into the closet. Pieces of rag used for wiping away the discharges 
from the patient must be burnt immediately after use (see 
Bed-Pans). 

5. All crockery, knives, forks, &c, used by the patient should 
be placed in disinfectant solution, and subsequently washed in hot 
water. 

6. The patient's body should be kept scrupulously clean, and 
the bed ventilated during the day. If scales or crusts form 
upon the skin they may be smeared with ointment or oil, 
containing antiseptics, to prevent their dispersion. 

7. JSurses or attendants should, if possible, be of mature age, or 
such as have already had the patient's disease; their dress should 
be of cotton or material that will wash easily. Before taking 
meals and before leaving the room the hands should be carefully 
washed in carbolic solution. They should avoid, as far as possible, 
inhaling their patient's breath or the emanations from the skin or 



ON FEVERS. 113 

other discharges. They should avoid all unnecessary communi- 
cation with the other members of the household. On ceasing 
attendance they should observe the rules for the disinfection of 
their clothing, and disinfect themselves by warm baths, paying 
particular attention to the cleansing of the hair. The skin should 
be well sponged all over with a warm solution of carbolic (1-40), 
and then washed all over with soap and water. The nails should 
be cleaned with the solution, and a nail brush used. 

8. If visitors have to be allowed under exceptional circum- 
stances they should be made to conform to the rules observed by 
those in attendance. 

9. The patient must not be allowed to mix with others until 
he has received permission from the medical attendant, and until 
he has been disinfected by the use of warm baths, and sponging 
with carbolic solution. Clothes that have been exposed to infec- 
tion must not be worn until they have been thoroughly disin- 
fected. 

10. Disinfection of the Room, Clothing, and Contents. — When 
the patient is convalescent and has left the sick-room, all the 
articles which cannot be dealt with at home, such as bedding, 
drapery, curtains, and outer clothing, should be sent away to the 
" oven " which is usually provided in certain districts by the 
health authorities for purposes of disinfection, and who will 
remove them if applied to. There they are subjected to a heat of 
from 212°-250° F. for several hours. 

Clothing and other materials remaining in the room should be 
spread out and hung upon lines fastened across the room, and all 
other articles exposed ; the doors, chimney, wundows, and all 
openings must be well closed and covered by pasting brown paper 
over the crevices before fumigation. For fumigation take half a 
pound or more of sulphur, according to the size of the room, break 
it into small pieces, and place it in an iron dish or pan, and then 
set it alight with a few live coals. The dish should be supported 
over a pail of water by placing the tongs across as a precaution 
against fire. The attendant should at once leave the room on 
lighting the sulphur, and close the door. The room may be kept 
shut up for twenty-four hours. At the end of this time the room 
should be freely ventilated by opening the windows and doors, 
and all its contents exposed to the air. The floor should be well 
scrubbed, and re-papering, painting, and white-washing would be 
extra precautions. 

Sinks and closets which have been used during the illness should 
be well flushed with disinfectant solution, and afterwards thoroughly 
scrubbed down and ventilated. 



114 A MANUAL OF NURSING, 

Infectious Fevers. 

THE INFECTIOUS FEVERS are chicken-pock, scarlatina, 
small-pock, measles, typhus, typhoid, diphtheria, mumps, and 
cholera. 

Incubation and Invasion Periods. — The infectious fevers have 
several characters in common. After the entrance of the 
infectious material into the x body, a period of time elapses in 
which no symptoms of illness are apparent ; this quiescent interval 
is called the incubation period. The length of this period varies 
in the different fevers, and is apt to be inconstant. At the end of 
incubation, the period of invasion commences with symptoms of 
illness of varying intensity. There is commonly chilliness, loss of 
appetite, lassitude, or headache. In some patients a rigor denotes 
the onset, or in children convulsions or vomiting. The tempera- 
ture is elevated and the pulse quickened, and the other symptoms 
of feverishness appear. 

The rash or exanthem will come out a day or more after the 
illness commences, the length of the invasion period being peculiar 
to each fever. 

VARICELLA, or CHICKEN-POCK, is most common in 
children, but may attack adults. The incubation period is usually 
from a week to a fortnight. The invasion is often so mild as 
to escape notice, and the rash appears in twenty-four hours. The 
eruption takes the form of minute papules and vesicles appearing 
on the chest and trunk, head and limbs. They often come out in 
crops, increase in size, become flattened, and the fluid inside is of 
milky colour. They burst and dry up forming scabs, which finally 
disappear, but may leave some slight scarring. The crops last four 
or five days each, and the course of the whole disease from a fort- 
night to three weeks. 

Management. — The disease is a mild one, and not usually 
attended with severe symptoms or high fever. The patient should 
be separated from other children, and put on light diet. No 
special treatment is necessary. Children should be prevented 
from scratching or picking the vesicles which may ulcerate and 
cause sore places, in which case simple dressings will be required. 

SCARLATINA, or SCARLET FEVER, is a disease which 
attacks children and adults in preference to older people ; it 
is frequently epidemic, and highly infectious. The incubation 
period is often short, less than a week, and the rash comes out on 
the second day of the illness. The invasion is sudden, and usually 



OX FEVERS. 115 

marked by chills, vomiting, and sore throat. The rosy or red rash 
appears first on the chest, and is seen early on the flexor aspect 
of the joints. It becomes general in the course of forty-eight 
hours, and is fully developed on the third or fourth day. The 
other symptoms continue or increase during the development of 
the rash, and the throat presents a dusky red appearance, with 
swelling of the tonsils. The tongue may present the character- 
istic strawberry dike appearance, a white fur with red papillae 
projecting. The rash begins to fade on the fourth to the sixth 
day of the disease, and disappears in a day or two ; the other 
symptoms also decline, and the temperature comes down. Peeling 
of the skin or desquamation next commences on the chest and 
other parts of the body, and lastly on the limbs, and hands and 
feet. 

In a mild epidemic of the disease the symptoms are of slight 
character, indeed, in some patients they escape notice, and the 
rash itself maybe overlooked. Some desquamation may be observed 
afterwards, and the disease in this way is easily spread. 

In others the attack is severe, and in some dangerous or fatal. 
The rapidly fatal cases die from profound nervous complications, 
such as delirium or coma, or else from extreme prostration, a few 
days after the onset ; such cases are termed " malignant," and are 
usually associated with defective sanitary arrangements. 

In severe cases the throat symptoms are predominant, the 
tonsils being much swollen or ulcerated, with sloughing patches. 
Complications liable to occur are rheumatism, pericarditis, inflam- 
mation of the internal ear, and empyema. During convalescence 
inflammation of the kidney with albuminuria and dropsy may 
appear in the third or fourth week. 

Management. — Immediate separation of the patient from other 
individuals should be insisted on, and an observance of the 
ordinary precautions for the management of infectious cases (see 
Isolation and Disinfection), In mild cases no particular remedies 
are used, and the fever will run its course. In those complicated 
with severe sore throat, and where there is difficulty in swallowing, 
pieces of ice may be given to suck, or steam inhaled, or the throat 
washed out with chlorine-water. AVarm mdk is usually well 
taken, and in cases where there is much depression some form of 
stimulant is required. During convalescence in the third and 
fourth week a carefid watch should be kept on the condition of 
the urine, as kidney-complications are apt to ensue. This would be 
indicated by the presence of blood in the urine, or by albuminuria, 
with perhaps some gastric disturbance, and dropsy of the eyelids, 
face, or feet. The urine should be examined for albumen con- 



116 A MANUAL OF NURSING. 

stantly, and if this begin to appear the medical attendant should 
be informed. Cold or chills should be scrupulously avoided by 
confinement to bed, the bowels should be freely open, and the diet 
restricted, the nitrogenous elements, such as meat, beef-tea, eggs, 
being avoided. 

Desquamation. — The surface of the body should be well oiled 
with carbolised oil to disinfect the skin before it peels. Warm 
baths, and the use of carbolic acid soap, are a great assistance to 
the peeling, which often continues for six or more weeks after the 
fever. In any case the patient is not safe as long as desquamation 
persists, and the hands and feet should be carefully inspected 
before he is allowed to mix with others (see Disinfection). 

SMALL-POCK or VAKIOLA.— Before the discovery of vac- 
cination, this disease was one of the most dreaded scourges of the 
country, owing to its great fatality, and from the extreme disfigure- 
ment of many who survived the attack. Xowadays, in those 
who have been efficiently protected by vaccination, small-pock 
assumes a modified form, in some of a very mild character. 

The incubation period is from twelve to fourteen days. The 
invasion is often sudden, with rigors, vomiting, headache, and 
pain more or less intense in the lumbar region of the spine. On 
the third day the eruption appears in the form of small reddish 
papules on the face, neck, and wrists, and gradually spreads to the 
other parts of the body. The spots are hard, and feel like shot 
under the skin, and enlarging in two or three days become vesicu- 
lar, and in six days contain pus. At this time the surrounding 
skin becomes inflamed and red and swollen. The pocks then 
subside and dry up, forming scabs. 

The constitutional symptoms and fever vary greatly in intensity, 
but on the first appearance of the rash these all subside in a 
marked degree, until the sixth or seventh day when the vesicles 
mature and become pustular ; there is again an increase in the 
fever, and the constitutional symptoms may be more severe than at 
the commencement, and attended with delirium and a dry tongue. 
The rash also appears in the throat and fauces, and may cause 
great soreness and pain in swallowing. 

Management. — A large, airy, well ventilated room should be 
procured if possible, and the precautions for isolation rigidly 
adopted. The nurse selected should be one who either has had 
the disease, or has been thoroughly protected by vaccina- 
tion. 

In mild or modified cases the disease runs its course without 
occasioning any anxiety. In the " confluent," or severe forms, a 



ON FEVERS. 117 

fatal result is common in the unvaccinated, or symptoms of the 
gravest kind may be present. 

When there is great soreness of the throat, warm bland drinks 
may be given, and if there is much discharge from the nostrils or 
fauces, some mild astringent wash may be used. The local treat- 
ment of the rash is important to prevent abscesses, and to modify 
the soreness of the pustules. The patient should be kept clean, 
and frequently sponged with tepid water. The condition of the 
eyes should be watched, as pustules may form on the conjunctiva. 
The surface of the body may be anointed over with carbolised or 
olive oil every day after sponging; and a drop of castor oil inserted 
into the eye, if there is much irritation. The face may be dusted 
with powdered starch or zinc powder. When the scabs are hard, 
black, or offensive, a bread or charcoal poultice may be applied to 
loosen them and allow the matter to escape. 

MEASLES. — The incubation period lasts from twelve to four- 
teen days. The invasion period is marked by symptoms of a cold 
in the head and some feverishness. There is sneezing, running at 
the eyes and nose of watery mucus, a patchy redness of the 
mouth and fauces, and perhaps an irritable cough. On the fourth 
day the eruption begins to appear about the neck and behind the 
ears, and on the forehead, and then on the chest, gradually invad- 
ing the rest of the body and extremities. It attains its height in 
from two to three days, and then gradually declines. The rash 
consists of small red papules which increase in size, and form 
crescents or irregular circles. There is some branny desquamation 
for a week afterwards. The complications likely to occur in 
measles are those affecting the lungs, such as bronchitis and 
inflammation of the lungs. Inflammation of the ear and ear-ache, 
or conjunctivitis, may supervene. Diarrhoea is an ordinary com- 
plication, and is troublesome in some cases. In the more severe 
cases delirium and great prostration is present, and gangrene of 
the cheek or vulva in delicate feeble children is sometimes a fatal 
event. 

Management. — The contagion of measles is very active at an 
early period before the appearance of the rash when the catarrh 
is present. When measles is epidemic, this catarrh should create 
suspicion, and separation be enforced at once. Children should be 
placed in bed at once, and care taken to avoid chilling of the sur- 
face, or anything tending to aggravate the cough or produce pul- 
monary complications. If these occur they will require special 
management (see Bronchitis). 

Attention should be paid to complaints of ear-ache in children, 



118 A MANUAL OF NURSING. 

and any discharge noticed. Aperients should be avoided, as the 
subsequent diarrhoea may prove troublesome. 

During convalescence precautions against cold are necessary, as 
some delicacy of lung, or general debility, is often left in children, 
especially in those of tubercular taint. 

TYPHUS. — Putrid fever, or gaol fever, are other names for this 
fever, which is occasioned mainly by overcrowding, destitution, and 
dirt. 

The early symptoms are characterised by great dulness and 
mental confusion, with quick pulse and fever. After the fifth or 
sixth day the mulberry coloured rash of small spots appears, with 
petechias (see Petechice). 

The constitutional symptoms are grave, and delirium, or coma with 
great prostration, may forebode a fatal result. The urine is retained, 
and the faeces passed unconsciously, and the patient sinks from 
exhaustion, bed-sores, or pneumonia. In favourable cases the 
symptoms abate, and the temperature subsides, perhaps suddenly, 
during the third week. 

Management. — In addition to the ordinary observances, con- 
stant stimulation will be required in bad cases, and complete con- 
finement to bed. Careful attention to the bladder and to the 
prevention of bed-sores is requisite, when there is much insensi- 
bility. A peculiar odour has been noticed in this disease, which 
is said to be characteristic. There is sometimes some difficulty in 
the early stages in distinguishing typhus from measles and 
haemorrhagic small-pox. The disease is most fatal in children 
and old people, but epidemics are rare now in this country, and a 
solitary case occurs only now and then. 

TYPHOID or ENTERIC FEVER— This disease may occur 
at any period of the year, but is commonest in the autumn months, 
and though attacking persons at all ages is essentially a disease of 
early life. 

The specific contagion is contained abundantly in the stools and 
emanations of typhoid patients, and it may be conveyed to others 
by means of drinking water, milk, or by the effluvia from infected 
drains, or from the different excretions of the patient. Epidemics 
of typhoid fever are common, and may often be traced to an 
impure water supply, or to the milk supply from an infected dairy. 
Direct contagion from the patient or the stools is not infrequent 
in the case of nurses or attendants of a youthful age. 

The nature of the disease consists essentially in inflammation 
and ulceration of the Peyer's glands of the intestines. In the 



OX FEVERS. 



119 



earlier period, during the first week, there is swelling of the glands, 
and these ulcerate during the second and third weeks, when the 
slough separates, leaving the bowel very thin at this part, until 
healing has occurred during the fourth and fifth weeks. 

Symptoms. — No two cases are exactly alike, but an instance of 
an ordinary attack may be given by way of example : — 

After a week or more of general indisposition and increasing 
lassitude the patient takes to his bed. He has a heavy dull look; 
the face pale, with slight flush on the cheeks. The tongue is 
moist, red at the tip and edges, with a light white fur in the 
centre. The abdomen may be rather tumid and tender, and the 



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motions are usually loose. The stools are commonly of light 
yellow colour, and of the consistence of pea-soup. The tempera- 
ture is elevated, being higher at night than in the morning. The 
pulse and respiration are quickened, and a bronchial cough is often 
present. About the tenth day, or between the seventh and twelfth, 
a rash appears in the majority of cases. The rash consists of 
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120 A MANUAL OF NURSING. 

the patient is characterised by weakness and prostration with 
stupor, and wandering at night. 

Towards the end of the third, or in the fourth week, the tongue 
begins to clean, and the temperature gradually falls, reaching the 
normal about the end of the fourth week. Convalescence is 
gradual and slow, and commonly without serious drawbacks 
(fig. 43). 

Relapse. — In a certain number of cases, after a week or fourteen 
days from the time the temperature gained the normal, the tem- 
perature again begins to ascend, and fresh rose spots appear, with 
a repetition of the original illness, though of shorter duration; 
this is called a "relapse." One or more relapses may occur, and 
they are usually less severe than the first attack (fig. 44). 

More severe cases are indicated by a higher temperature, of 
105° or 106°, or by great prostration, a dry brown tongue, or 
profound nervous symptoms of delirium and stupor. 

In typhoid fever, whether mild or severe, certain complications 
may occur at certain periods, with which the nurse should be 
acquainted. In the early stage, or during the first ten days, 
serious complication is uncommon, there is sometimes slight 
bleeding from the bowel or nose. 

Death in the early stage of typhoid fever is rare. 

After the second week the complications are more dangerous. 

Severe Diarrhoea, with eight or ten watery evacuations during 
the twenty-four hours, may cause great prostration. 

Hemorrhage from the bowel should be watched for, a few 
ounces need not cause alarm but half a pint or more repeated at 
intervals is dangerous. 

Peritonitis and Perforation. — The former is always of grave 
import and sometimes fatal, and the latter almost certainly fatal. 

Bronchitis and Pneumonia. — Some bronchitis is commonly 
present, and need not cause anxiety unless severe, or accompanied 
by lividity and difficulty in breathing. Pneumonia is apt to 
supervene very insidiously, and may be indicated by short rapid 
breathing, pain in the side, or blood-stained sputum. 

Bed-sores are very easily produced from the wasting of the 
tissues, lying in one position, involuntary evacuations, and other 
causes, and should be guarded against (see Bed-Sores). 

Management. — A successful issue in typhoid fever depends in 
great measure on careful nursing, to a greater extent in this than 
in any other disease. A knowledge of the nature of the fever 
will assist the nurse to understand the reason of the precautions 
observed in managing these cases, and to be prepared for the 
complications which are likely to occur in the several stages. 



ON FEVERS. 



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122 A MANUAL OF NURSING. 

The patient should be put to bed after receiving a warm bath, 
or if too ill for a bath, he may be sponged all over with warm 
water; at this time any spots should be noticed, and their position 
observed. It is advisable to cut the hair quite short after 
attending to the head. A water-bed should be used from the 
first. In most cases of typhoid, drug treatment is unnecessary, 
but perfect rest, careful feeding, and sleep are essential, and the 
complications will also require special management. 

Perfect Rest. — Friends should be excluded as far as possible, 
and the patient must be kept absolutely quiet in bed, and lying 
down. During the middle and later periods of the disease, 
moving in the bed should be accomplished gently and gradually. 
Fatal perforation of the bowel has occurred from sitting up, or 
walking about during the stage of ulceration. 

Diet and Feeding. — Exhaustion and emaciation are prominent 
features in the disease, and the patient requires constant nourish- 
ment. Milk is by far the best form of diet, and two to five pints 
may be given in the twenty-four hours freely diluted with water, 
barley water, or soda water. If well taken nothing else need be 
given, but if disliked, or if it does not digest but forms lumps of 
curd, it will have to be substituted by beef-tea, veal or chicken 
broth, and eggs beaten up. Koumiss, or peptonized milk, will 
sometimes agree when plain milk fails. Coffee and milk, and 
iced water, may also be allowed. In great prostration nutrient 
enemata of milk, brandy, and port wine may be required. 

The intervals at which the patient should be fed depend on 
the severity of the case. In mild cases, where a good quantity 
can be taken, nourishment every four hours will be sufficient. 
In severe cases, with prostration or stupor, or when there is great 
loathing of milk or fluids, and when the tonpue is dry and 
brown, with crusts or sordes on the lips, feeding is difficult ; 
but a successful result depends on the administration of nourish- 
ment. The difficulty may be diminished by first cleansing the 
mouth, tongue, and lips with lemon juice and glycerine or water, 
and then the nourishment, two or three ounces, should be given 
in a feeder or spoon every one or two hours. Natural sleep should 
not be heartlessly broken for the exact hour of feeding, but a 
condition of stupor or prostration must not be mistaken for sleep, 
and then the patient should be aroused to be fed. 

Stimulants are unnecessary in ordinary cases, and where 
nourishment is well taken, but in the worst cases life may 
depend on them. Eight or ten ounces of brandy or whisky may 
be required daily, or a bottle of champagne, or half a bottle of 
port : occasionally, more can be taken with advantage, but 



ON FEVERS. 123 

the amount of stimulant will be prescribed by the medical 
attendant. 

In the fourth week, or when the patient is beginning to feel 
better, there is often a craving for solid food, and attempts may 
be made to persuade the nurse to humour him in this respect, 
especially by the friends, who are not aware of the danger. 
The walls of the bowel are very thin where the ulceration has 
occurred, and if solids, or undigested hard bodies, such as pips, 
&c, are swallowed, a hole may be made in the bowel, and fatal 
peritonitis ensue. The temperature is the best guide in ordinary 
cases as to the administration of solid food, and it is wise to wait 
until the temperature has kept at or about normal for a week 
or ten days before any solid food is allowed. White fish is best 
in the first instance, followed after a while by chicken, sweet 
bread, light milk puddings, &c. 

Sleep. — It is important for the nurse to be careful to distin- 
guish between a state of stupor and natural sleep. The latter is 
highly beneficial, and should be undisturbed for four or five hours 
if the nourishment has been previously well taken. In stupor 
or prostration the patient must be aroused at intervals in order to 
take nourishment. If good sleep is difficult to obtain, a small 
dose of alcohol at night is often successful. In other cases, tepid 
sponging, especially if the temperature is high, is very comforting, 
and procures sleep. 

Diarrhoea. — Several loose motions in the twenty-four hours is 
natural in typhoid fever, and requires no treatment. When exces- 
sive, such as eight or nine copious fluid watery evacuations, the 
patient's strength becomes reduced. Enemata of starch and 
opium is a safe remedy, and is often prescribed, or the administra- 
tion by the mouth of opium in some form. Beef-tea should be 
avoided while the diarrhoea continues. 

Constipation is common in the mild forms of typhoid fever 
and during convalescence. In the early stage it is safe to clear 
the alimentary tract by castor oil and enemata. Afterwards the 
bowels should be left alone unless the constipation lasts more 
than four or five days, or there is evidence of lumpy faecal matter 
in the rectum, when an enema of oil in small quantity may be 
slowly and gently administered. Aperients by the mouth should 
never be given by the nurse, except under express orders from the 
medical attendant. 

Motions. — The poison which conveys the disease is abundantly 
contained in the motions. It is absolutely necessary to disinfect 
these immediately; therefore, on removing the bed-pan from the 
patient, a strong solution of carbolic acid (1-20) should be at once 



124 A MANUAL OF NURSING. 

poured in before emptying and cleaning it in the usual way 
(see Bed-Pans). Some soft material, such as old linen, tow, or 
absorbent cotton-wool should be used to cleanse the patient, and 
this must be immediately burnt. The nurse must always wash 
her hands in disinfectant solution after attending to the patient. 

Haemorrhage. — This may take place from the nostrils or 
bowel. The former is often the result of picking the nostril, and 
is usually insignificant. Haemorrhage from the bowel during the 
first fortnight is commonly beneficial or harmless, and does not 
need interference. In the third week and later if copious, half a 
pint or more, it is dangerous, and often fatal if repeated. The 
medical attendant should be at once informed in order that 
drugs may be ordered, and ice applied to the abdomen. In 
these cases opium is useful, and alcohol may have to be withheld. 

Peritonitis. — The onset may be insidious in cases associated 
with much stupor, in others the symptoms and management 
would be similar to cases previously described (see Peritonitis). 
The peritonitis may be due to perforation of the bowel, in which 
case there is often sudden fall of temperature to sub-normal, with 
symptoms of collapse, such as great pallor, cold sweats, feeble 
pulse, syncope, &c. (see fig. 45). 

Pneumonia. — Inflammation of the lung occurs in a few 
cases in the course of the disease. It is often insidious, and 
usually dangerous, especially if associated with great prostration, 
dry tongue, &c. Stimulants are beneficial, and attention to the 
temperature and ventilation is specially required (see Pneumonia). 

Plugged Veins. — Swelling of the leg and pain in the groin are 
symptoms of a clot in the vein, and are sometimes attended with 
rigors. The patient should be kept lying down, with the leg 
raised and wrapped in cotton-wool, until the symptoms have 
subsided. 

Convalescence. — The temperature should be recorded morning 
and night for at least a fortnight after it has reached the normal, 
and longer if necessary. A relapse occurs usually from seven to 
ten days after the first illness, and is indicated by a fresh gradual 
rise of temperature, when the fluid diet must be resumed. The 
relapse lasts about fourteen days, and in a few cases a second 
relapse occurs. Slight rise of temperature of a temporary nature 
may be the result of excitement, or solid food, or first getting 
up. 

Great hunger is common during convalescence, and plenty of 
nourishment may be allowed after a while. Mental imbecility, 
or deafness, may persist in a few cases for a considerable time, 
but recovery is usual. 



ON FEVERS. 



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126 A MANUAL OF NURSING. 

DIPHTHERIA. — A highly contagious disease in which the 
throat is sore and presents patches of white membrane in parts, 
and associated with fever and other constitutional symptoms. It 
affects children and adults at any season of the year, but is far 
commoner in children. It may be epidemic, and more often 
attacks damp localities or insanitary houses ; other cases of 
ordinary sore throat are apt to prevail about the same time. 

The period of incubation may be very short, only a few hours, 
or several days. 

Symptoms. — The general symptoms vary in intensity, and may 
be slight at the commencement. The sore throat is often first 
observed, and the tonsils and uvula are reddened and swollen, 
and a membrane of whitish or greyish colour is seen on the 
tonsils and uvula, or some part of the pharynx. There may be 
some discharge from the nostrils, and the membrane may appear 
on wounds on the surface of the body. In moderate cases the 
general symptoms are well marked and accompanied by prostration 
and weakness. Swallowing is painful and difficult, and the 
glands of the neck are swollen. 

In severe diphtheria death may occur in a few days from 
jextreme depression and prostration of strength. 

LARYNGEAL DIPHTHERIA.— This is the most dreaded com- 
plication in children, and is one cause of the great fatality of the 
disease. Attendants on cases of diphtheria in children should be 
acquainted with the symptoms which indicate implication of the 
larynx, as these are apt to occur very suddenly, and in the night, 
and rapidly become urgent. 

The child's voice is noticed to be rather hoarse on crying or 
speaking ; there is a short dry cough, difficulty in breathing, and 
the inspiration becomes noisy and crowing. As the difficulty in 
breathing increases, the child becomes restless, and the lips and 
face bluish, and then drowsiness supervenes. 

Management. — The nurse should be prepared to carry out 
local treatment if required. This consists either in painting the 
throat with lotions of perchloride of iron, or antiseptics, or in the 
use of the spray by the ball-spray apparatus. During the applica- 
tion of these remedies the tongue should be depressed by the 
spatula. Coughing and expectoration are very apt to be pro- 
duced by the application, and the nurse should carefully avoid 
receiving the particles on her lips as she may easily thereby con- 
tract the disease. A respirator or temporary veil may be used to 
cover the mouth at the time she is making the application (see 
Throat Applications), 



ON FEVERS. 127 

In severe cases, constant nourishment is necessary to support 
the general strength. In all cases it is highly important that the 
room should be well ventilated and supplied with plenty of fresh 
warm air, without draught. The temperature of the room should 
be about 60° F. 

Children should be carefully watched at night for any indication 
of the symptoms of implication of the larynx, such as difficult 
breathing, &c, and the surgeon should be informed in case 
tracheotomy may be necessary (see Tracheotomy). 

Diphtheria is very fatal in children, either from exhaustion or 
suffocation. In a few cases sudden death occurs unexpectedly 
from syncope. If there is much prostration, or a tendency to 
faintness, the patient should be kept in bed and not allowed to 
get up. The urine must be saved and examined for albumen 
during the disease. 

Paralysis. — During convalescence, and even some months after- 
wards, there is a liability to a peculiar form of paralysis. This 
may be first indicated by a return of fluids through the nose 
during swallowing, or a nasal character in the voice, or weakness 
in the muscles of the legs or back ; or perhaps squinting and 
shortness of sight may be first noticed. The paralysis may be 
slight in character and limited, or it may invade a large number 
of the muscles of the body. Recovery is commonly complete in 
a few weeks or months. Massage, warmth, and attention to the 
general health will assist recovery. 

MUMPS. — This disease affects children and young adults at 
any season of the year. There is inflammation and swelling of 
the salivary glands, attended with some general feverishness. 
The swelling produces a peculiar rounded look about the face, in 
front of the ears, and under the chin. One side of the face is 
often first affected and then the other, and swallowing is usually 
painful. In a few cases the inflammation attacks the generative 
organs. 

Management. — The patient should be confined to the room, 
and the face and neck protected by cotton-wool or soft flannel. 
Pain may be relieved by hot fomentations, and care taken to 
avoid cold or draughts. Light fluid diet should be given at first. 
There is often general debility and feeble health for some time 
afterwards. 



128 A MANUAL OF NURSING. 

ASIATIC CHOLERA.— A disease known by vomiting and 
purging, and accompanied with rapid collapse of the vital powers. 
Asiatic cholera is rare in this country, but epidemics have been 
started by the importation of the disease from foreign parts. 

Symptoms. — The disease comes on suddenly, or is preceded by 
diarrhoea ; the stools are very copious, resembling rice-water. 
Cramps of a violent kind attack the muscles of the abdomen 
and extremities, and when collapse sets in the skin is cold and 
covered with clammy sweat ; the nails turn blue, the eyes are 
sunk, and the features look pinched, while the pulse fails, the 
breathing becomes laboured, and the urine is diminished in 
quantity or suppressed. 

The symptoms are sometimes divisible into three stages. 

The first stage is marked by " premonitory diarrhoea/' depres- 
sion, and nausea. 

In the second stage, the stools become more frequent, and the 
fluid ceases to be bile-stained, becoming colourless, and like rice- 
water ; vomiting ensues, with cramps in the muscles of the ex- 
tremities and abdomen ; there is great thirst, the voice becomes 
husky, and the face pinched. 

From this stage, which lasts from two to fifteen hours, the 
patient passes gradually into the third, algid, or collapse stage, the 
purging and vomiting diminish or cease, the temperature becomes 
subnormal, the face and extremities acquire a leaden hue, the eye- 
balls are sunken, the face hollow, and the voice sinks to a whisper. 
The urinary excretion becomes scanty or suppressed, and the skin 
is covered with a clammy perspiration. 

Death may ensue in about twenty-four hours from the com- 
mencement. A stage of reaction may precede death, or in 
favourable cases herald the recovery. 

Management. — Rest in bed and abstinence from all food are 
the first directions in a case of cholera. Counter-irritation to 
the pit of the stomach by a. mustard-poultice helps to relieve the 
depression. Small quantities of ice, iced water, or sulphuric 
lemonade, may be allowed to relieve the thirst. Cramp may be 
alleviated by gentle rubbing with the hand, or by hot applications. 
In the collapse stage, hot blankets and hot bottles should be 
ready, brandy or champagne may be of use, or, if the diarrhoea 
has ceased, enemata of beef-tea or brandy may be given. Injection 
of fluids into the veins is sometimes practised in this stage with 
good results. 

During reaction small quantities of nutritious fluids may be 
constantly given at short intervals, but if suppression of urine 
continues, the patient may be allowed to drink more freely. 



ON FEVERS 



129 



Precautions to be observed by the Nurse in Cholera Cases-. 

1. To attend to her own health, by ensuring regular meals, 
sufficient sleep, and not too long- continued attendance in the sick- 
room. 

2. To practise absolute cleanliness; to wash and disinfect 
her hands after attending to the patient, before her meals, and 
before leaving the room ; not to partake of meals or food in the 
sick-room. 

3. To prevent the spread of disease in the house by self- 
disinfection, cleanliness, and disinfection of all discharges, excreta, 
utensils, and other articles from the sick-room. (See also Rules for 
Disinfection, page 112.) , 

4. Disinfection and disposal of excreta, &c. For the purposes 
of the sick-room, such as the disinfection of soiled handkerchiefs, 
sheets, and the like, as well as for the swabbing of floors, carbolic 
solution (1 to 20), or preferably the perchloride of mercury solution, 
may be used.* The latter may usually be procured from the 
Sanitary Authorities. 

In places provided with proper systems of excrement disposal, 
the excreta, after being treated in detail with the disinfecting 
solution in ample quantity, may be safely put into the ordinary 
closet, but special care as to the flushing of the drains and sewers 
is necessary. When the only closet is one that communicates 
with a cesspool or privy-pit, the best arrangement that can be 
found practicable will have to be adopted, but advice should be 
immediately obtained from the Sanitary Authorities. 

5. Disinfection of the room and its contents. After occu- 
pation by a cholera patient, the room and its contents should be 
disinfected by the Sanitary Authorities. 



Instructions issued by the Local Government Board for the 
Prevention of Cholera. 

The chief instructions given by the Local Government Board 
to be followed for the prevention of cholera, when this disease 
threatens to approach, are as follows : — 

* Perchloride of mercury, a cheap and efficient disinfecting fluid, is thus 
prepared : — Dissolve half an ounce of corrosive sublimate and five grains of 
commercial aniline blue in three gallons of water, and add thereto one 
fluid ounce of hydrochloric acid. Preserve in earthenware jars or wooden 
tubs. The aniline blue is intended to colour the solution, which is highly 
poisonous, 

I 



130 A MANUAL OF NURSING. 



Instructions issued by the Local Government Board for the 
Prevention of Cholera — continued, 

1. As Cholera is not in the ordinary sense of the term " con- 
tagious," and is rarely, if ever, communicated like small-pox or 
scarlet fever directly from person to person; as it is probable 
that those in attendance upon Cholera patients are not more 
liable than others to be attacked, and as it is certain that 
physical and moral depression favour the liability to contract the 
disease, apprehensions should be allayed, confidence encouraged, 
and that manner of living pursued which experience has proved 
to be conducive to the best state of health. 

2. The house should be clean, dry, and well ventilated. 
Air-shafts, traps, and drains should be in perfect working order. 
Dust-bins should be frequently emptied, and no decaying matters 
of any kind should be permitted to remain in or near the 
house. 

3. As water is one of the chief agents by which choleraic 
infection is conveyed, all water employed for personal and domestic 
use in the household should be scrupulously protected from con- 
tamination of every kind ; and if any doubts of its purity arise, the 
water should be boiled, filtered, and consumed within twenty-four 
hours. 

4. The dietary should consist of three or four meals daily. The 
food should be fresh and thoroughly cooked, the vegetables well 
boiled. Simply cooked wholesome fruit may be eaten. Milk 
should be boiled before use. 

Alcoholic beverages should be taken in great moderation, and 
only at meal-time. 

It is desirable to avoid soups, tinned or otherwise preserved 
provisions, raw or stale vegetables, unripe, over-ripe, or decaying 
fruits, pastry, cheese, nuts or other indigestible things, malt liquors 
turning hard, ginger beer, coarse oatmeal gruel. Too long fasts, or 
too frequent feeding, should be avoided. 

t Cooking utensils should be scalded after use, and kept carefully 
clean. 

6. Avoid the use of strong aperients, and especially of strong 
saline aperients. If there is obstinate constipation, take at bed- 
time either a teaspoonful of Gregory's powder or one or two tea- 
spoonfuls of castor-oil. 

7. Avoid excess and irregularities of all kinds, over-fatigue, pro- 
longed watchings, emotional excitements, undue mental strain, and 
all things that exhaust the nervous system. Especially avoid the 



ON FEVERS. 131 

frequent use of alcoholic or other stimulants to cover sensations of 
sinking, malaria, or depression. 

8. If, notwithstanding a careful regulation of the manner of 
living, looseness of the bowels should set in, send immediately for 
medical assistance; until this arrives, the following instructions may 
be followed: — Retire at once to bed in a warm but well-ventilated 
room, and if troubled with cramps or pains apply hot applications 
to the abdomen. Take two teaspoonfuls of castor-oil in a little 
hot milk. 

Should the diarrhoea continue after the action of the castor- 
oil may be fairly supposed to have ceased, relief may be ob- 
tained by taking a few doses of ordinary diarrhoea mixture, 
but any further measures should be carried out under medical 
direction. 



INFLUENZA. — Epidemics of influenza occur from time to time 
at varying intervals. Previous to that of 1889, there was an 
interval of fifty years, in which there had been no outbreak in 
this country. 

The disease usually begins in the East, and spreads with great 
rapidity over the world. When it attacks a town or city, a large 
proportion of the inhabitants become attacked almost simultane- 
ously, and the numbers of persons affected during an epidemic is 
greater than in any known epidemic disease. 

The malady is highly infectious, and is probably in great 
measure conveyed along lines of human intercourse. 

Symptoms. — The onset of the disease is usually sudden, and is 
marked by chilliness and shivering. The temperature is raised, 
the skin hot, and the pulse quickened. 

Frontal headache with severe pain at the back of the eye-balls 
is common, and the eyes have often a pink appearance from small 
congested vessels. Pain in the limbs, back, and chest may be very 
severe, or present in a less degree of severity. 

Catarrhal symptoms, such as those accompanying an ordinary 
cold, may be present or entirely absent. Prostration of strength 
is a characteristic common to the disease, whatever form it may 
take. 

Gastric symptoms may be the most prominent in some 
patients, in others ordinary catarrhal or bronchial affections pre- 
dominate. 

Pneumonia is a dangerous complication, and is responsible for 
a large number of the fatal results. 



132 A MANUAL OF NURSING. 

Mental symptoms are not uncommon in the course of the 
disease. 

The majority of persons attacked by influenza recover com- 
pletely, though in many the convalescence is very protracted. In 
others, and especially in those of delicate health, the disease 
leaves permanent effects behind, or is the starting-point of 
tuberculosis or other serious maladies. 

Management. — In ordinary cases, rest in bed for a few days 
until the fever and other symptoms have subsided, and confinement 
to the house until convalescence is complete, is all-sufficient. 
Fluid diet during the fever, and good nourishment as soon as 
the patient is able to take it, are requisite, as on account of the 
attendant prostration any lowering treatment is not well borne. 

Severe complications have often been the result in the case of 
persons who have not laid up in the early stages of the malady, or 
who have too soon exposed themselves to the risk of cold or over- 
work. 

Non-Infectious Fevers, 



NON-INFECTIOUS FEVERS.— There is no danger of the 
malady being communicated to others, and the precautions with 
regard to disinfection are unnecessary. As examples may be 
given, Rheumatic fever and Malarial fevers or Ague. The latter 
are frequently endemic in certain low-lying districts, or in tropical 



RHEUMATIC FEVER, or ACUTE RHEUMATISM, affects 
the joints, and is usually the effect of cold, damp, or exposure, in 
those who have a tendency to rheumatism. 

Symptoms. — The joints, either the ankles or knees, wrists or 
elbows, become swollen and painful, and the patient is unable to 
use them; at the same time the temperature of the body is 
elevated, and the skin is covered with profuse perspiration of acid 
odour. In addition, there are other symptoms of constitutional 
disturbance, and the urine is loaded with thick red deposit. 

The complications in rheumatic fever are — inflammation of the 
valves of the heart and pericardium, pleurisy and pneumonia, and 
excessively high temperature, or hyper-pyrexia. 

Management. — The patient should be clothed in light flannel, 
and may lie between the blankets. Owing to the profuse per- 
spiration, all exposure should be avoided, and the room well 



ON FEVEKS. 133 

warmed. The joints should be moved with great care and 
wrapped round in cotton-wool or light flannel, and the pressure 
of the bed-clothes taken off if necessary. Getting out of bed must 
be entirely forbidden. The diet allowed is usually milk, alone, or 
with some farinaceous food, while beef-tea and other nitrogenous 
diet is strictly excluded. In most cases after the administration 
of salicylic acid in some form, the temperature rapidly subsides, 
and the pain and swelling of the joints diminish, so that in a 
few days the disease is controlled. 

Relapse is very common if this drug be left off too soon, or if 
unsuitable diet is resumed, or if the patient leave his bed at a too 
early period. It is the practice of many physicians to commence 
the treatment of the disease with full doses of salicylic acid after 
the bowels have freely acted ; and since patients differ in their 
ability to tolerate this drug without unpleasant symptoms, the 
nurse should be familiar with the symptoms of overdose. These 
are — noises in the ears, deafness, giddiness, headache, stupor, 
delirium ; further, heavy, noisy breathing, with depression of 
strength, and possibly blood in the urine or haemorrhages from 
other regions. The drug is generally administered until it pro- 
duces some giddiness and deafness, with noises in the head, and is 
then gradually diminished, if the symptoms of overdose are pro- 
minent, or when the temperature falls, as it often does rapidly. 

Pericarditis is a severe complication of rheumatic fever, and 
notice should be taken of any complaints of pain in the region of 
the heart, or of shortness of breath, lividity, &c (see Pericarditis). 

High Temperature, or Hyper-pyrexia, is an occasional com- 
plication of great urgency. In a case of rheumatic fever the 
nurse should take the temperature constantly, every four hours, or 
oftener if required. Should the temperature continue to ascend 
and rise above 105° with nervous symptoms, such as stupor and 
drowsiness, reaching perhaps 106°, 107°, or up to 1 10° with coma, 
the patient will die unless the temperature soon be reduced. 
The cold bath treatment is the most rapid and eiheient method, 
and it will have to be given under the superintendence of the 
medical attendant (see Baths). 

Convalescence is sometimes rapid ; in others there is lasting 
debility, or heart-disease, or stiffness of the joints. In all there 
is a tendency to recurrence, and flannel garments or Jaeger's under- 
clothing should always be worn next the skin. 

MALARIA, AGUE, or INTERMITTENT FEVERS.— Indi- 
viduals living in marshy districts in this country, or who have 
resided abroad where these fevers are common, are liable to this 



134 A MANUAL OF NURSING. 

affection, which may continue to attack them many years after 
they have left the region in which they contracted the fever. 

Symptoms. — In the common form of this fever there are three 
stages, the cold, the hot, and the sweating stage, the whole attack 
lasting some hours. Between the attacks there is an intermission 
of a varying duration of good health. The patient is usually 
attacked suddenly with a sense of chilliness and increasing feeling 
of cold. The teeth chatter, and there is general trembling of the 
limbs. The extremities become blue and the face pinched, and 
the urine is copious. If the temperature is taken it is found to 
be above the normal, and going up rapidly. After this the hot 
stage commences, and the sense of chilliness diminishes. The 
warmth increases until the heat becomes intense, the face flushed, 
and the skin dry and pungent. This stage may last several hours, 
and is succeeded by the sweating stage, in which the skin becomes 
bathed with profuse sweat, the temperature falls, and the other 
symptoms of discomfort disappear. 

Management. — The nurse may apply warmth during the cold 
stage by different methods — warm blankets, hot bottles, packing, 
&c, during the hot stage tepid sponging and light clothing, and 
if there is much thirst fluids may be administered. When 
drugs, such as quinine, opium, or antipyretics, are ordered, the 
temperature should be taken regularly at short intervals before 
and after the drug is administered ; the observations being noted 
on the chart in order that the effect of the remedies on the 
temperature may be ascertained. 

Individuals suffering from ague should be warned not to go out 
at night or in the early morning in malarial regions, but should 
choose the middle of the day. They should also occupy a bed- 
room in the upper part of the house. 



CHAPTER IX. 

Disease in Children. 

Observation of Children — The Cry — Attitude in Bed — Complexion- 
History of Illness — Disorders of Infancy — Wasting — Feeding- 
Artificial Food— Teething — Convulsions. 

Symptoms and Management of Rickets — Laryngismus — Thrush — Sore 
Throat — Gastric Catarrh — Constipation — Obstruction — 
Diarrhcea — Infantile Cholera — Chronic Diarrhoea — Typhoid 
Fever — Worms — Tubercular Meningitis — Water on the Brain. 

Introduction : Observation of Children. 

Information concerning children's symptoms or previous ailments 
has to be gathered from the mother or nurse, who only are 
constantly in contact with them both in health and in disease, 
and are thoroughly familiar with their methods of expressing 
their wants and feelings. 

Observation of Children. — In the case of infants, or children 
under two years old, it is not always an easy matter to compre- 
hend the signs of suffering, or to refer them to their real cause, 
but a great deal may be discovered by careful attention. An 
infant makes known its wants, and gives expression to its feelings 
of distress chiefly by crying. 

The Cry, as described by Dr Eustace Smith in his work on 
Children's Diseases, is often characteristic. " A hungry infant in 
most cases clenches his hands and flexes his limbs as he utters his 
complaints, and continues until satisfied. If tortured by colicky 
pain, the cry is violent, paroxysmal, and accompanied by uneasy 
movements of the body. A shrill scream uttered at intervals, the 
child lying in a drowsy state with closed eyes, is suggestive of 
tubercular meningitis. A constant unappeasable screaming is 
often the consequence of ear-ache, and the child frequently presses 
the side of the head against the mother's breast. The pain of 
pleurisy will also cause violent crying. Any alteration in the 
quality of the cry must be noted. It may be hoarse in a young 
infant from inherited syphilis ; and in an older child from laryn- 
gitis." Absence of crying is often indicative of exhaustion or 
serious disease. 



136 A MANUAL OF NUKSING. 

Attitude in Bed. — The child's position in its cot should be 
carefully observed. Healthy children usually lie partially on the 
side, with the cheek on the pillow. In exhaustion or serious 
disease, the infant often lies on his back, with closed eyes and 
face directed upwards. Lying on the side, with the head partially 
retracted or thrown back on the shoulders, is suggestive of brain 
affection, or, if associated with difficult breathing, of laryngeal 
mischief. Lying on the belly with the face pressed into the 
pillow, or the thighs and legs flexed on the abdomen, may indicate 
abdominal discomfort. 

The Complexion of the healthy infant should be clear and 
fresh, and any alteration, such as sallowness, pallor, lividity, or 
a muddy colour, suggests derangement. A haggard expression, 
contracted brow, or sunken hollow eyes are also the result of 
disease. 

The frequency of the pulse and respiration, and the temperature 
should be noted; the latter often rises with very slight reason 
to a height which, in an adult, would probably be associated with 
severe disorder. 

The state of the skin should also be noticed as an indication of 
how the child has been cared for, whether dirty, or covered with 
scabs, parasites, or eruptions. 

History of Illness. — In hospital practice, when the nurse 
receives a sick child from the mother or relatives, she should make 
a point of ascertaining the following particulars before they leave: — 

Name — Age — Birth : Premature or full-time — nursed or hand- 
fed — child's previous ailments : .specific fevers, eruptions, &c. — 
History and symptoms of present illness, giving dates : — Family 
history : Father, mother, residence, number of children alive — 
miscarriages, still-born children, and ailments of living children 
— children who have died, and cause of death. 

Information of this kind, and other particulars relating to the 
cause or circumstances of the illness are of great value, and 
cannot be obtained in many cases except by the nurse, who has the 
opportunity of seeing the child's relatives. 

For the convenience of the physician on his visit the child may 
be stripped naked in a warm room, wrapped up in a blanket, 
and then placed in the nurse's lap, if a complete examination is 
desired, and the child is not too ill. 

Disorders of Infancy. — Owing to the extreme excitability of 
the nervous system in children, slight functional disorders are apt 
to give rise to signs of considerable general distress. For instance, 
stomach derangement, or indigestible food, may cause high fever, 
rapid breathing and cough, or perhaps a convulsive seizure. In 



DISEASE IN CHILDREN. 137 

feeble children some functional disturbance, apart from any actual 
disease, may be very serious or even fatal. In long continued or 
exhausting diseases there is often loss of this nervous suscepti- 
bility. Sudden death is common in infancy, especially associated 
with exhaustion from diarrhoea and vomiting, or from laryngismus 
or convulsions. 

Wasting, Inanition, and Bad Feeding. — Amongst the poorer 
classes a large number of infants, apart from actual disease, remain 
small, thin, pale, and instead of increasing in size become more 
and more emaciated. "Want of air, unhealthy houses, and deficient 
clothing are amongst the common causes, but bad feeding is 
the commonest of all. 

Feeding. — A healthy infant should be nursed by the mother 
for the first seven or eight months, and requires no other food. 
During the first month or six weeks it may receive the breast 
every two hours during the day and less often at night. After- 
wards it should wait for longer intervals. At seven months one 
or two meals a day may be added, consisting of Chapman's, 
Mellin's, or Ridge's food, or Robb's biscuits, mixed with milk. 

At ten months it may be weaned, and a little broth, beef-tea, 
or gravy added to its meals. On no account should the baby be 
kept at the breast after ten months, a custom Avith some mothers, 
but injurious both to the baby and to herself. 

At eighteen months pounded meat and light puddings may be 
given. 

If the mother's milk fail, or is not available, the infant will 
have to be brought up by hand. 

Artificial Feeding. — For the first two months condensed milk, 
in the proportion of one teaspoonful to half a bottle of water, or 
thin barley-water may be given ; or cow's milk in equal parts 
with water, or barley-water, or with two tablespoonfuls of liniQ- 
water added. The addition of the barley-water or lime-water 
prevents the milk from curdling in the stomach. The proportion 
of the milk to the water may be increased as the child gets older. 
Cow's milk requires sweetening with sugar, or sugar-of-milk, and 
it should be warmed to a temperature of 95°. The bottle should 
be kept thoroughly clean, and the milk and barley-water kept in 
a cool place when not required. Preserved milk should be kept 
covered, and the barley-water must not be boiled after it has 
been made, as it is apt to ferment. 

The best form of bottle is the straight one with an india-rubber 
teat, and without tubes and corks which are liable to become foul. 
The bottle should be rinsed out each time after using, and kept 
in water, and cleaned once a day with hot water and soda. 



138 A MANUAL OF NURSING. 

"With the exception of the artificially prepared foods mentioned 
above, farinaceous food should not be given to children under 
six months of age. It is a mistake to feed babies too often, or 
whenever they cry for it, just to stop their crying ; or when they 
grow older to allow them the same diet as adults because they 
enjoy it. 

Emaciated children, otherwise healthy, will commonly improve 
after their diet has been carefully regulated, and if one form of 
diet does not agree with them some other should be substituted. 
Cod-liver oil in small quantities, twenty drops or so, is an excellent 
food, and agrees well with many infants. It may be rubbed into 
the skin of the abdomen with the palm of the hand, if not well 
taken by the mouth. 

Warmth. — Infants are very susceptible to cold, and a low tem- 
perature may produce in them a variety of disorders. The room 
they occupy should be well ventilated, warmed, and kept at an 
equable temperature. Their clothing should be of flannel, light, 
and not too tightly applied. The legs and arms should be covered 
and protected from exposure out of doors. When indoors, they 
may, with advantage, be allowed to kick about and exercise 
their limbs. 

Teething Derangements. — The first dentition, or cutting the 
milk teeth, commences usually at the seventh month, and ter- 
minates at the end of the second year. 

The teeth should appear in the following order : — Lower central 
incisors, upper central incisors, upper lateral incisors, lower lateral 
incisors, first molars, canines, back molars. At twelve months 
the infant should have cut eight teeth. The order given above 
is not, however, constantly followed in all healthy children, and 
the time may be anticipated or delayed. Infants are liable to be 
feverish during dentition, and there is a tendency to irritability 
and restlessness ; chills are more easily taken, and the food is 
more likely to disagree, giving rise to pulmonary troubles, gastric 
derangement, or convulsions. Greater care is therefore necessary 
at this period to avoid cold, or sudden change of diet. If the 
gums are swollen and painful they may be gently rubbed with the 
finger moistened with fresh lemon-juice, but in a few instances it 
may be necessary to use the lancet. 

Convulsions. — Apart from disease of the brain and epilepsy, 
convulsive seizures are common in infants under two years old. 
Rickety children, or the offspring of nervous parents, are more 
liable to suffer. The existing cause is usually some distant irrita- 
tion which should be sought for. Commonly some gastric irrita- 
tion in the form of curdled milk, or undigested food, constipation, 



DISEASE IN CHILDREN. 139 

or intestinal worms, will account for it. Irritation of the ear 
from wax or other foreign bodies, or the cutting of a tooth, are 
often causes of fits. In a few instances a convulsion denotes the 
onset of a specific fever, and corresponds to a rigor in the adult ; 
fits are also common in whooping-cough. 

A convulsive seizure is usually sudden, though sometimes pre- 
ceded by restless excitability, accompanied by starting and twitch- 
ing during sleep ; the eyes have a staring look and are directed up- 
wards, and the thumbs are turned towards the palms of the hands. 
When the fit begins the child becomes stiff, the head is thrown 
back, the limbs straightened and fixed, and the breathing ceases. 
Soon afterwards the face becomes flushed, the eye-balls move from 
side to side, and the muscles of the face and body constantly 
twitch. There is loss of consciousness during the fit which lasts 
commonly for several minutes, and may recur. The face becomes 
pale and moist with sweat, the infant falls asleep, and on awaking 
seems to have recovered and to be in its usual health. 

Management. — For the convulsive attack a warm bath and the 
application of cold to the head is frequently ordered. 

An infant may be immersed in a bath of the temperature of 
90° F., cold sponges being placed on the head, and constantly 
changed. Ten to twenty minutes, according to the age of the 
child, is a sufficient length of time to continue the bath, unless 
there has been previously great exhaustion, when five minutes or 
less is sufficient. Afterwards the room should not be too hot, and 
the child should lie lightly covered in the cot. An enema of 
soap and water may be given if the bowels have been confined. 

In children who are liable to convulsions, or who have pre- 
viously been attacked, the symptoms before the onset should be 
noticed, and care taken to avoid those sources of irritation which 
seem to induce an attack. The bowels should be kept open, the 
food carefully chosen, chills avoided, and during dentition extra 
precautions in these various ways should be taken. The majority 
of infants survive an ordinary convulsion, but in some cases the 
fit terminates fatally, especially if there is a succession of them. 

Diseases of Children. 

RICKETS. — This disease is essentially one which attacks 
infants belonging to the poorer classes in large towns, though it 
occasionally appears amongst the well to do. Ead feeding and a 
defective supply of fresh air are the two main causes of rickets, 

Symptoms. — It is unusual for these to appear before the sixth 
month or after the second year, but once begun they may continue 



140 A MANUAL OF NURSING. 

in one form or another for several years. The time of weaning 
seems to determine the commencement in many infants, and 
symptoms of digestive derangement appear and continue. The 
motions are more frequent, offensive from undigested food, and 
pasty looking, or of greenish colour. The child is irritable and 
fretful, and dislikes to be handled on account of tenderness of the 
body and limbs \ the colour of the skin is sallow and unhealthy 
looking, the cheeks pinched, and there is a tendency to copious 
perspiration about the head at night. The coverings of the bed 
are thrown off, and the infant may be found asleep resting on its 
elbows and knees, on account of flatulent disturbance and pain in 
the belly. The head is enlarged and the abdomen distended ; the 
teeth are late in appearing, and the fontanelle is wide open after 
the second year, the time at which it should have closed. The 
bones too are found to be misshapen, especially the extremities of 
the wrists and lower leg bones, which appear swollen ; and small 
rounded swellings are liable to occur in the ribs near to the breast- 
bone. As the child grows older these deformities may increase, and 
the shape of the chest be distorted, especially if the infant is 
attacked by pulmonary disorders to which they are unusually 
liable, causing the condition known as pigeon-breast. The shape 
of the long bones of the legs is influenced by standing and walking, 
and the bones being weak are bent and curved in various ways 
by the weight of the body. 

Rickets is not usually fatal in itself, but death may occur from 
complications, such as pulmonary complaints, convulsions, water 
on the brain, laryngismus or spasm of the glottis, or gastric 
derangements and diarrhoea. 

Management. — It is necessary first to inquire how the infant 
has been fed, the kind of food, and the number of meals given at 
the present date. The clothing should be noticed, and inquiries 
made about the ventilation of the room, and whether the child is 
ever taken out of doors. Amongst a large number of the poor 
and working classes, attention to these {particulars is not possible, 
nevertheless a good deal may be done in many instances 
towards improvement in the manner of feeding. On inquiring, 
it will often be found that the mother is keeping the infant at the 
breast up to two years old or longer, or else has been feeding the 
infant on cheese, beer, spirits, or anything that she may be having 
herself, saying that the child craves for it, and is not satisfied. 
AVhen the diet has been corrected and arranged (see Feeding)^ and 
directions given for cleanliness and fresh air, the state of the 
stomach and bowels should be ascertained, whether there is sick- 
ness, flatulence, or diarrhoea. 



DISEASE IN CHILDREN. 141 

It is a good plan to apply a warm flannel binder round the 
abdomen, which is often sufficient to remedy the intestinal de- 
rangement, but in long standing or obstinate cases drugs will be 
required. When the bowels are brought to a natural state, great 
improvement in the general condition will follow, and cod-liver 
oil may be given with advantage. From ten to twenty drops to 
half a teaspoonful is sufficient, according to the age. 

"When the child arrives at the age for standing or walking, it 
should not be allowed to bear its full weight on the legs, as the 
bones being weak will become bent and curved, producing 
deformity of a more or less permanent kind. 

The pulmonary complications of rickets require the ordinary 
measures and precautions necessary in these cases (see Bron- 
chitis). 

LARYNGISMUS, or FALSE CROUP, is a spasmodic attack of 
difficult breathing, and is fatal in some instances. It may be pre- 
ceded by a crowing sound with breathing, and then suddenly the 
breathing ceases, and the infant becomes stiff, and the face dark 
and livid ; this lasts for a few seconds, and then the spasm relaxes 
and the breath is drawn in with a crowing noise ; vomiting, perhaps, 
occurs afterwards. The attack may produce or be associated with 
a convulsion, or the attack of laryngismus may be repeated. 

Management. — "When there is time a hot sponge should be 
placed against the outside of the throat, or the back of the fauces 
may be tickled with the finger to produce vomiting. In some 
instances the attack may be controlled by holding a bottle of 
smelling-salts to the child's nose. The return of the paroxysm 
may be prevented by regular cold bathing three times a day, the 
body being rapidly and thoroughly sponged with cold water. 

DISORDERS OF THE ALIMENTARY CANAL— Apthse 

Thrush. — Infants and young children are liable to disorders 
of the mucous membrane of the mouth, especially when teeth- 
ing, or when there is some digestive disturbance. White patches 
of thrush are apt to form on the inner surface of the lips, 
gums, and palate, or else small vesicles form and break, leaving 
circular, shallow ulcers, with a whitish surface on the mucous 
membrane. In either case they are associated with stomach 
derangement, and are of no great consequence in strong children, 
but in those who are suffering from chronic diseases, or exhaus- 
tion, they are of serious import. 

Management. — The most suitable local treatment is to cleanse 
the affected part with warm water, afterwards applying a solution, 



142 A MANUAL OF NURSING. 

consisting of half a drachm of borax to an ounce of glycerine, 
with a camel's hair brush. 

Gangrenous Inflammation. — More serious forms of ulceration 
and gangrenous inflammation of the cheek or mouth occur 
sometimes in children after specific fevers, or in those of un- 
healthy or debilitated constitution. 

Management. — In these cases nourishment and stimulants 
have to be freely given, and the surgeon may find it necessary to 
destroy the gangrenous parts with caustics. The local after- 
treatment, consisting mainly in the constant application of anti- 
septic solutions, may have to be carried out by the nurse. 

SORE THROAT AND ENLARGED TONSILS.— Children of 
all ages are liable to affections of the throat, and complaints of pain, 
soreness, or difficulty in swallowing ought to be attended to. 
The throat should be inspected, and a good view may often be 
obtained by gently pinching the nostrils together while the 
mouth is held open and a deep breath drawn in. Kedness of 
the fauces, tonsils, and uvula should be noticed, and it should be 
observed whether there is a patch of white membrane, as in 
diphtheria, or if the tonsils are red, swollen, or project unusually 
into the throat, as in quinsy. A red mottling of the throat is 
sometimes seen early in scarlatina. 

Management. — Throat affections should be seen early by the 
medical attendant, and in any case it is advisable that the child 
be immediately separated from other children until his visit, in 
case the throat should betoken the onset of one of the infectious 
fevers. 

In chronic enlargement of the tonsils, the breathing is apt to 
be heavy and laboured, snoring at night is common, and some 
deafness is likely to supervene as the child grows older. In 
young children, if the enlargement is great, deformity of the 
chest may be induced by the difficulty in breathing. 

GASTRIC CATARRH— Symptoms.— This ailment has been 
mentioned in connection with rickets and as the result of improper 
feeding of infants, but it also affects older children as the result 
of a chill, an error in diet, or a scrofulous habit. The onset may 
be sudden with feverishness, cough, and rapid breathing, the 
tongue is coated with white fur, and there may be sickness 
and constipation. There is sometimes a watery discharge from 
the eyes and nose, and the fauces may be reddened. In some 
children there is slight delirium at night. The urine is usually 
turbid and high coloured, and there may be slight jaundice of 



DISEASE IN CHILDREN, 143 

the skin. The temperature may rise to 104° or 105° in the 
evenings, but descends in the morning. These attacks may occur 
without fever or with only slight febrile symptoms, and they 
have a tendency to recur. The febrile form bears a close re- 
semblance to enteric fever in young children. 

Management. — Children who suffer from this disorder, and 
show a tendency to recurrence, should • wear a broad flannel 
bandage, extending from the arm-pits to the hips, and applied 
firmly as a protection from cold, but it should be taken off at bed- 
time. During the attack the character of the excretions should 
be noticed, and whether there is a tendency to acidity of the 
stomach or sour-smelling breath. 

Diet. — The diet is all important, sweets and starches in any 
quantity should be avoided, also fruits, cakes, potatoes ; while 
freshly made broths, milk, and lime-water, and unsweetened 
barley-water should be allowed. Purgatives are best avoided, and 
the action of the bowels regulated by mild aperients such as 
liquorice powder or castor oil. During convalescence, fish, fowl, 
and mutton may be taken, and farinaceous food only in small 
quantity. Cold bathing in the morning will strengthen the 
system against recurrence. 

Constipation is a common trouble in children and infants of 
all ages. In young infants it is natural for the bowel to be 
relieved several times in the twenty -four hours, so that one motion 
a day would indicate constipation. In older children the bowel 
may not act more than once every two days without any symptoms 
of further disorder ; but evidence of headache, languor, loss of 
appetite, and sallow complexion would indicate that the con- 
stipation was harmful. 

Flatulence and colic are often associated with constipation in 
infants, as shown by constant crying and flexing the thighs 
on the abdomen ; the motions are hard and lumpy, and voided 
with pain. In many cases the child restrains efforts at evacuation 
on account of the pain produced by the passage of the lumps. 
In some the hard faecal matter irritates the bowel and causes 
partial diarrhoea, which is only relieved by remedying the constipa- 
tion and irritation ; obstruction of the bowel may result from long 
continued constipation. 

Management. — The child should be trained at an early period 
to go punctually to the stool every morning, and regularity enforced 
until a habit is formed. 

In younger children and infants the diet, consisting in a large 
degree of farinaceous food, has a tendency to produce dry faecal 
matter. The amount of this food will have to be lessened where 



144 A MANUAL OF NURSING. 

constipation exists. Extract of malt, one or two teaspoonfuls a 
day, or manna dissolved in warm water and added to the food 
are useful. Friction of the abdomen with the hand is found to 
be effective in some cases. "When accumulation is present, a 
suppository of castile soap, or a small enema, or a dose of castor 
oil may be given, or a small teaspoonful of glycerine may be 
introduced into the rectum with a syringe. 

Xurses should not take upon themselves the responsibility of 
constantly dosing children with aperients without medical sanction, 
as much harm may be done to weakly infants by aperients inju- 
diciously administered. 

OBSTRUCTION OF THE BOWEL in infants may be caused 
by " intussusception " or by a rupture. 

Symptoms. — In the former the symptoms may commence with 
sudden pain in the abdomen, screaming, vomiting more or 
less persistent, and obstinate constipation, though there may be 
some action of the bowels at first. After a while there is 
commonly a discharge of blood and mucus from the bowel, with 
much straining, and the other symptoms continue. The infant 
appears exhausted and the countenance pinched and haggard, and 
there may be a protrusion of the bowel from the anus. Coldness 
of the extremities and collapse supervenes, and the child dies 
if the bowel is not relieved. 

Management. — Unless these cases are recognised in the early 
stage there is not much chance of recovery, and the nurse should 
immediately summon medical aid instead of waiting, perhaps, 
until after the mother has given frequent aperients, and collapse 
is imminent. 

The treatment will have to be carried out by the surgeon, and 
consists in endeavouring to replace the bowel by giving enemata, 
or injecting air into the bowel. 

For rupture, see Hernia. 

DIAKRHCEA. — The mortality from severe diarrhoea in infants 
is very large, but slight attacks are frequently prevalent. 

Symptoms. — In its simplest form, resulting from improper 
feeding, teething, or a chill in a healthy child, it is a mild disorder, 
and ceases when the exciting cause has been removed. It is 
attended with griping pains, restlessness, vomiting, and slight 
fever. The motions are at first loose and lumpy, with undigested 
material, of sour odour, and perhaps frothy from fermentation; 
subsequently they become thinner, watery, and mixed with 
greenish mucus. 



DISEASE IN CHILDREN. 145 

Management. — The child should be kept warm, and at the 
commencement, especially if the motions contain undigested 
material and there is griping pain, a small dose of castor oil 
should be given. 

Diet. — In a hand-fed baby the milk should be well diluted 
with barley-water or lime-water, and starchy material or other 
unsuitable food withheld for a time. 

SUMMER DIARRHOEA and INFANTILE CHOLERA.— 

Acute and severe forms of diarrhoea are apt to attack infants and 
young children residing in large towns, and these may be especially 
fatal and dangerous during the late summer or early autumn 
months, so that the term summer or autumnal diarrhoea has been 
applied to them. The exciting causes may be similar to those in- 
ducing the simpler forms of diarrhoea, such as indigestible food, or 
chills, but there would seem in many instances to be some epidemic 
influence from soil or sewer drainage. Epidemics occur more often 
after or during hot, dry summer weather, and an immense number 
of cases of simpler and milder forms of diarrhoea may precede the 
epidemic. Infants and children of the poorer classes are more 
liable to be attacked than others. 

Symptoms. — The early symptoms resemble in the main those 
of simple diarrhoea, but soon become intensified ; the vomiting is 
more constant, of sour and acid fluid. The purging is more violent, 
the stools numbering from six or seven to fifteen or twenty in the 
twenty-four hours. Their colour varies, but is often dark 
coloured, or green, frothy, and very offensive, and there may be 
some slimy mucus tinged with blood. The general symptoms 
are severe ; there is rapid wasting, and the face changes its aspect, 
the eyes become hollow, the skin pale and wrinkled, and there is 
great depression of strength. The temperature may be elevated 
to 102° or 103°. If the disease continue, the tongue becomes 
dry and brown; the pallor and pinched look about the face 
increase, and the eyelids droop but remain partially open during 
sleep ; the fontanelle is found to be depressed, and the extremities 
cold. The infant may die either suddenly from syncope, or 
gradually from exhaustion. 

Older children are better able to withstand the exhausting 
effects of the vomiting and purging, and there is less danger. 
The young infants or weakly children are very soon brought into 
a critical state by the exhausting effects of purging. 

Management. — "When an epidemic of autumnal diarrhoea pre- 
vails in the neighbourhood, some extra care should be exercised in 
the management of infants and young children, and attention paid 

K 



146 A MANUAL OF NURSING. 

at once to symptoms of gastric disorders or looseness of the bowels. 
Aperients or purgatives should be avoided, or given with great 
care. Purity of air in the nurseries should be ensured, excite- 
ment should be avoided, and early hours insisted on. 

Diet. — In infants at the breast, and hand-fed babies, the 
diarrhoea is apt to be increased or kept up by the use of milk, and 
it will have to be diminished, or altogether suspended for a time. 
Barley-water, or whey, in equal parts, or weak chicken broth, 
given cold, will have to be substituted. Koumiss has been 
found to agree in some instances, and when given to young 
children the gas should be first got rid of. TVhen the exhaustion 
is great, or if collapse seem to be imminent, four or five drops of 
brandy may be given at once, or two or three drops every three or 
four hours according to the age. In older children the diet 
should consist of plain whey, barley-water, weak veal- or chicken- 
broth, or if necessary brandy and yolk of egg. Whenever milk is 
given it should be mixed with lime-water or barley-water. In 
all cases the abdomen should be kept warm with flannel, and hot 
applications placed on the extremities if necessary. 

In chronic diarrhoea the symptoms are less urgent, but there 
may be very great wasting and weakness. In addition to the 
general rules with regard to diet in diarrhoea previously given, the 
milk and starchy foods must be restricted, and their place taken 
by stronger meat-essences, broths, or meat-juice in some form. In 
older children raw meat especially prepared is of great service 
(see Appendix), 

TYPHOID FEVEK and ULCERATION OF THE BOWELS. 

■ — Typhoid fever is less common in infants and young children 
than in adults, and it has a tendency to run a milder course. 

Symptoms. — The early symptoms are vague, but there is 
usually headache, listlessness, and loss of appetite, with some 
fever. In the second week there is usually some tenderness and 
distension of the abdomen, and the bowels may be relaxed. The 
fever increases, and there is thirst and nocturnal delirium, with 
some drowsiness. The spots characteristic of typhoid may appear 
in crops, or may be entirely absent. The course of the fever 
differs from that in the adult, chiefly in its milder character, a 
rather shorter course, and frequent absence of spots. Bed-sores 
are less common than in the adult, but boils and abscesses may 
occur, and debility and rnental weakness may persist for some 
time after the fever. 

Management. — The same careful nursing and feeding as de- 
scribed under typhoid fever in adults is requisite (see Typhoid Fever). 



DISEASE IX CHILDREN. 147 

Diet. — For young children milk, broths, and water may be 
allowed in fair quantities when there is great thirst. In giving 
drink to thirsty children, not only in typhoid, but in any other 
case, the nurse should be particular to put the whole amount 
intended for them to drink at one time into the glass, and allow 
them to drink it all. Young children do not understand that 
they must not have more than a certain amount, and if a full 
glass is given, and they are only permitted a few sips, they cry at 
once for more. 

In typhoid and other cases of ulceration of the bowels, tuber- 
cular or dysenteric, a flannel bandage may be worn with advant- 
age round the abdomen. The motions should, in all cases, be 
examined and saved for inspection if there is anything unusual. 

INTESTINAL WORMS.— These parasites are very common 
in children, and are caused by drinking impure water, or eating 
imperfectly cooked food. 

There are three common forms, thread worms, round worms, 
and tape worms. 

Thread Worms. — These small white worms are like fine 
threads ; they measure from a sixth to half an inch long, and 
reside in the large bowel just inside the external orifice, where 
they cause great irritation and itching. They may be observed in 
the motions. 

Management. — The most effective method of removing thread 
worms is by the use of enemata. The bowel should be first 
cleared by a copious injection of warm water, and afterwards five 
or six ounces of a solution of common salt, in the proportion of 
one teaspoonful to four ounces of water, should be injected and 
retained for a few minutes ; or the same quantity of an infusion 
of quassia may be employed instead. Great cleanliness of the 
parts should be insisted upon, especially after action of the bowel, 
warm soap and water being used if necessary. An ointment, 
composed of one drachm of powdered camphor to an ounce of 
lard, is useful to allay the itching inside the orifice. 

Round Worms. — These long worms resemble in shape and 
appearance an earth worm, only they are white or yellowish-white, 
instead of red in colour. They inhabit the stomach or small 
bowel, and are a common source of symptoms of gastric irritation 
in children. The child seems never satisfied after food, and is 
fidgety, picking the nose and rubbing its eyes ; the tongue and 
mucous membranes look red, and the nutrition of the body suffers. 
In some cases severe symptoms of nervous disturbance, or bowel 
derangement, may be created in infants and young children by the 



148 



A MANUAL OF NURSING. 



presence of these worms. They may be solitary, or many in 
number, and may be passed spontaneously by the bowel, or be 
vomited from the stomach, or they may crawl out of the mouth 
or nose while the child is asleep. 

Tape Worms. — Segments or joints of white, flat, tape-like 

appearance, of about half an inch in 
length, and a quarter of an inch across, 
"2 are sometimes voided with the motions. 
These are portions of the tape worm, 
which is many feet in length when 
complete (fig. 46). 

The segments are broader at the 
centre, and become smaller and finer as 
they approach the head, which is globular 
in form, and of the size of a pin's head, 
so that it commonly escapes detection. 
The worm gives rise to intestinal de- 
rangement and diarrhoea, but produces 
no very special symptoms, and can only 
be detected by the presence of the seg- 
ments in the stools. 

Management. — The nurse should 
make herself acquainted with the common 
forms of worms that infest the alimentary canal in order that 
she may recognise them. Specimens of the round worm, or 
ascaris, and of the tape worms, or taenia, may be found on 
the shelves of most museums. Once known they are unmis- 
takable, but otherwise an error might be made in confusing quite 
different substances with them. Casts of white membrane are 
sometimes shed from the bowel in large quantities, of irregular 
shape, which might be mistaken for worms by the inexperienced. 
Worm powders of various kinds are prescribed, usually consist- 
ing of santonin, for the expulsion of worms. To be effective 
it is necessary that these remedies should be given on an empty 
stomach ; they are best taken in the early morning, and should 
be followed by a brisk aperient ; the remedy being repeated in a 
day or two if not successful. If the last meal is taken early, 
they may be given at bed-time, an aperient being taken in the 
morning. The excreta should be carefully examined afterwards 
to see if the worm or worms have been passed. 




Fig. 46.— Tape Worm 
1. Head. 2. Tail. 



TUBERCTJLAE MENINGITIS.— Infants and children of all 
ages suffer from this very fatal disease, and the offspring of delicate 
or consumptive patients are especially liable to be attacked. 



DISEASE IN CHILDREN. 149 

Symptoms. — The premonitory symptoms in children may be 
of some duration, consisting of listlessness, languor, loss of flesh, 
pallor, and alteration in temper and manner. The onset may he 
gradual or sudden, with headache, vomiting, feverishness, flushed 
face, constipation, drowsiness, and irritability when awake. The 
headache is usually constant, with paroxysms of great severity, 
causing the child to shriek or cry out suddenly ; the senses are 
very acute, strong light or loud noises causing distress. After 
a varying period the so-called second stage sets in. The headache 
is more severe, and the brows are contracted ; there is great irrita- 
tion on being disturbed, but there is increasing drowsiness and 
stupor, and delirium is frequent ; the pupils may be dilated, or 
a squint may be noticed. The urine is often retained, or there is 
incontinence. The face is pale with a tendency to flush, and the 
pulse and temperature descend. The third stage supervenes with 
increasing stupor or complete coma, and in addition there may 
be twitching of the limbs, or a general convulsion. The tempera- 
ture may rise considerably before death, which occurs usually 
under a fortnight from the onset, though the length of the illness 
is very variable. In a few cases there is a return of consciousness, 
more or less complete, shortly preceding the fatal termination, but 
coma again returns. There are few diseases which may present so 
variable a course and uncertain symptoms as tubercular meningitis, 
but constant severe headache, vomiting, and constipation are 
prominent symptoms which should rouse suspicion of head mischief. 
Other acute brain affections in children, such as abscess, or simple 
meningitis, present symptoms of the same character as iubercular 
meningitis, but the chance of recovery is rather more favourable. 

Management. — The nurse may be able to do a great deal 
towards the alleviation of the sufferings of the child; and although 
a fatal termination is almost a certainty in an undoubted case of 
tubercular meningitis, there are many others in which the exact 
nature of the affection must remain uncertain, and in which an 
unexpected improvement in the symptoms changes the aspect, and 
a favourable termination ensues. 

On receiving a child in hospital suffering from head symptoms, 
the nurse will do well to inquire for any strumous or consumptive 
taint in the parents, family, or other children. Blows on the head, 
discharge from the ear, overpressure at school are also points 
concerning which information may be obtained. The child should 
be placed in a quiet room, cool and well ventilated ; the light 
must be shaded by a dark curtain, the hair may be cut short or 
shaved if ordered, and cool applications kept in contact with the 
scalp. The feet should be warmed, and the bowels relieved by an 



150 A MANUAL OF NURSING. 

aperient or enema. Liquid food in small quantities should be 
given at intervals, and ice if there is vomiting. Nursing or 
moving the child about should be avoided, tending to increase 
the headache, and liability to sickness. When coma supervenes 
the usual precautions as to the excretions will have to be taken. 

WATER ON THE BRAIN — HYDROCEPHALTJS. — This 
chronic affection is due to an accumulation of the natural fluid in 
the interior of the cavities of the brain, and shows itself soon after 
infancy. The infant's head is noticed to be larger than usual, and 
continues to enlarge ; the forehead and sides seem especially 
prominent, and the fontanelles show no sign of closing in, so that 
soft places are felt extending along the top and sides of the 
skull. The face appears unnaturally small in size, and the eyes 
look prominent and staring ; nervous symptoms are usually present. 
The majority of children thus affected die during infancy or quite 
young, and those who live are defective in intelligence, and 
terminate their lives in a lunatic asylum. 



CHAPTER X. 

Wounds and their Complications. — Ulcers, Burns, 
and Scalds. 

Incised and Lacerated Wounds — Healing by first Intention, by 
Granulation — Dressings — Scalp and Face Wounds — Cut Throat 
— hemorrhage i capillary, venous, and arterial — arrest of 
Bleeding — Inflammation and Abscess — Pus or Matter. 

Symptoms and Management of Cellulitis — Erysipelas — Poisoned 
Wounds — Pyjemia or Blood-Poisoning— Tetanus — Ulcers and 
Ulceration — Burns and Scalds. 

Introduction ; Different kinds of Wounds. 

Wounds may occur from various causes, and present endless 
variety of shape and position. They may conveniently be 
divided into Incised, Contused, and Lacerated Wounds. 

INCISED WOUNDS.— Simple cuts of superficial extent are of 
slight consequence if properly attended to, and will often heal 
readily of themselves. Any dirt should be washed off, a strip of 
plaster applied to bring the edges of the wound together, a pad 
of lint bandaged over, and the wound will usually heal quickly 
and without trouble. 

Healing by first Intention. — In these cases the edges of the 
wound are rapidly glued together, and there is a very slight scar 
or cicatrix left. This method of healing is called union by first 
intention, and is the quickest and most favourable that can be 
desired. 

Extensive and deeply incised wounds are accompanied with 
severe haemorrhage (see Hcemorrhage). After the bleeding has 
been stopped the surgeon often has to insert some stitches or 
sutures of wire or silk to keep the edges in position, and to enable 
the wound to heal, as far as possible, by the first intention. 

Contused and lacerated wounds are accompanied by somo 
damage to the skin and soft parts, and the skin may be partially 
destroyed, and the tissues bruised and torn. These wounds are 
usually produced by blows or blunt instruments, or by gunshot 



152 A MANUAL OF NURSING. 

accidents or explosions. They sometimes contain a considerable 
quantity of dirt or foreign bodies of various kinds. 

Healing by Granulation. — There is little chance of their healing 
by the first intention, as new skin has to be formed where the 
skin has been destroyed, and the deeper parts of the wound must 
first unite together before the surface heals over. In cases where 
wounds do not heal by first intention there is more inflammatory 
action, and matter is formed on the surface of the wounded 
parts. After a time small red spots appear in the deeper parts 
of the wound which bleed easily, and are called granulations ; 
these sprout up and gradually fill the gaps, while the edges of the 
wound uniting by degrees the skin grows over the surface and 
the wound is healed. This method of healing is much slower 
than union by first intention, and the cicatrix is more distinct 
and permanent. 

The Management and Dressing of wounds, either the result 
of accidents or after operations, has frequently to be undertaken 
by the nurse. The particular dressing to be used will, in most 
cases, be decided on by the surgeon, but while attending to the wound 
the nurse should observe the following important details : — 

In the case of incised wounds of small extent, a piece of strap- 
ping of sufficient size to cover the whole wound should be applied, 
the part having been previously dried, and the edges of the 
wound brought neatly together, and bandaged if further support 
is necessary. The wound will frequently heal perfectly by the 
first intention and no further dressing be required ; in fact, the 
less disturbed it is the better, unless there is evidence of inflam- 
mation. If the plaster is well heated by wetting in boiling water, 
it will remain secure until the wound is healed. 

If the wound is of considerable length, the plaster is best 
applied in strips, about one inch broad, and of sufficient length 
to extend some distance on either side of the wound. In apply- 
ing each strip one end should be first fixed down, and then the 
edges of the wound drawn together by the thumb and finger of 
the other hand, the plaster can be then brought over the wound 
and finally fixed on the other side ; a small space should be left 
between the several strips of plaster, and a bandage may be 
advantageously used to assist in keeping the parts together. 

In dressing lacerated wounds, discharging wounds, or those 
containing dirt, it is of the greatest importance to cleanse them 
thoroughly first. This is best done by directing a stream of 
warm water either with a syringe, or by other means, into the 
wound until all particles of dirt and discharge have been removed. 
Instead of simple water a lotion composed of one part of carbolic 



WOUNDS AND THEIR COMPLICATIONS. 153 

acid to sixty of water, or a weak solution of Condy's fluid, may 
be employed. If dirt or gravel or other material still remain 
fixed in the wound, a hot bread or linseed-meal poultice may be 
used for three or four hours before the dressings are applied. 
If the surgeon does not advise some particular dressing, strips of 
lint covered with eucalyptus vaseline, or carbolised oil may be 
laid over the wound, a pad of cotton-wool over this, and then a 
bandage used to secure the dressings in position. 

In dressing or re-dressing wounds, the nurse should endeavour 
to give as little pain as possible. The dressings required should 
all be prepared beforehand, and in addition, scissors, dressing 
forceps, syringe, basins and dishes, and boiling water should be in 
readiness. 

In removing strapping, it should be done gently, the two ends 
being unfixed and raised towards the wound, and the edges kept 
together by the thumb and the finger while the plaster is being 
peeled off. If it adheres to the hairs the process is painful and 
the hairs should be cut, but it is better to shave the spot before 
applying the plaster. 

In re-dressing extensive wounds, the old plaster should not all 
be removed until the new strips have replaced some of the old 
ones, thus preventing any undue strain on the wound. 

Where sutures have been applied, the nurse should be careful 
not to pull on them, and to notice especially whether there is much 
redness or inflammation round them, which is frequently the case 
if they have been in too long, and should report to the surgeon. 

In severe wounds of the extremities, a splint is required to keep 
the parts completely at rest. The padding in the neighbourhood 
of the wound should be covered with oiled silk or some other 
protective, to prevent the necessity of changing the padding every 
time, which would otherwise become soaked with the discharges 
from the wound. 

Wounds of the Scalp are of very common occurrence, as the 
result of a blow or a fall on the head. Owing to the looseness 
with which the scalp is attached to the parts beneath, large flaps 
are sometimes separated and torn, so that a very extensive wound 
is produced, and the consequent haemorrhage is often severe. 

Management. — After the wound has been thoroughly cleansed, 
the flaps should be replaced in position, and the hair cut short or 
shaved for a considerable extent round the wound. A pad of dry lint 
can be retained in position by a capeline bandage, handkerchief, or 
calico cap. In many cases the wound heals readily, but in persons 
addicted to intemperance, inflammatory action often sets in with 
suppuration, and perhaps erysipelas. The parts around a scalp 



154 A MANUAL OF NURSING. 

wound should be carefully examined at the time of dressing, and 
the nurse should notice if there is any swelling or bagging under 
the adjacent parts, indicating the formation of matter, or if there 
is any flush or redness about the part, and should report at once 
to the surgeon. 

In Wounds of the Face the edges should be very carefully 
adjusted in order to promote healing by first intention and secure 
as slight a scar as possible. If they are extensive the surgeon will 
probably insert sutures, which have to be removed after about 
forty-eight hours if wire has been used. They heal very 
readily, but occasionally erysipelas supervenes. 

Cut Throats. — In desperate cases, the haemorrhage from the large 
vessels in the throat may be so severe as to destroy life rapidly. 
In some patients there is the danger of suffocation if the windpipe 
has been laid open ; the blood flowing into the opening blocks up 
the passage. If there is evidence of this, the patient should be 
placed on his side or face, and the wound should on no account be 
covered up. 

After the immediate dangers have been passed, the position of 
the patient in bed is important. The shoulders should be raised 
by pillows, and the head bent forwards, and if necessary, in unruly 
cases, a bandage should be carried round the forehead, and the 
ends brought from the temples down to a waistband in front. 

There is risk of inflammation of the lungs from the access of 
cold air through the wound in the windpipe, which may be 
obviated by the application of hot, moist flannels, laid lightly over 
the wound. If the epiglottis or the gullet be wounded there may 
be difficulty in feeding the patient, and the administration of food 
or stimulants by the rectum rendered necessary for a time. 

Wounds of the trunk which penetrate the cavities of the chest 
or abdomen are dangerous according to their extent, and to the 
complications which may ensue from damage to the organs con- 
tained within them. They require early attention by the surgeon. 
In severe cases death may be immediate from shock or internal 
haemorrhage. 

Complications of Wounds. 

The complications of wounds are Haemorrhage, Inflammation 
and Abscess, Cellulitis, Erysipelas, Blood-Poisoning, and 
Tetanus. 

HEMORRHAGE or BLEEDING.— Loss of blood may occur 
from a wound of an artery, of a vein, or of capillaries. It is 



WOUNDS AND THEIR COMPLICATIONS. 155 

important to be able to distinguish them, as bleeding from a large 
artery is rapidly fatal if not controlled. In bleeding from 
wounded capillaries the blood is of bright colour, oozes into 
the wound and flows over, perhaps very briskly. AVhen the blood 
flows in a steady stream, and wells up in the wound, of a dark or 
blue-black colour, it comes from a wounded vein. But when an 
artery is wounded the blood is spirted out in jets with great force 
to a considerable distance, and is of a bright red colour, so that 
the amount of blood lost from a large vessel in a short time is 
very great. 

In the majority of wounds in which the capillaries are cut 
across, and even in some accidents where the artery is damaged 
by violent crushing or tearing, nature arrests the bleeding. In 
the case of wounded capillaries the blood forms a clot, which 
blocks up the open channels, and no further bleeding occurs. 
Where an artery is torn across or lacerated, the muscular and 
elastic coats will often contract and diminish the size of the 
orifice. The flow of blood is thus lessened or stopped, and this 
gives time for a clot to be formed which closes up the mouth 
of the artery sufficiently for the time, and if left undisturbed 
changes take place which permanently seal the wounds in the 
vessel. 

Methods of Arresting Haemorrhage. — If nature does not arrest 
the bleeding it is necessary to check it artificially. The means 
which a nurse can best employ in an emergency is pressure applied 
in various ways; at the same time attention must be given to the 
position of the wounded limb. 

Bleeding from Capillaries. — In a wound where there is free 
bleeding from capillaries, which does not cease when exposed to 
the air or after bathing with cold water, pressure may be applied 
in the form of a pad of several folds of lint, soaked in cold water, 
and firmly bandaged over. If the wound is on an extremity, the 
limb should be raised on a pillow and not allowed to hang down. 

Bleeding from a Vein, as for instance a wounded varicose vein 
in the leg, may be arrested by a pad placed on the bleeding spot, 
and tied on by a handkerchief or bandage, and the patient placed 
on a sofa with the leg well raised. If this is not sufficient a 
bandage should be applied firmly round the limb on the side of 
the wound away from the heart. 

Bleeding from Arteries. — To arrest arterial bleeding the finger 
or a pad should be applied to the bleeding spot, and pressure 
kept up until assistance can be obtained. The exact source of the 
bleeding may sometimes be ascertained by sponging away the 
blood out of the wound, and watching for the point where the jet 



156 



A MANUAL OF NURSING. 




of blood issues. If this fail, and the wound is of a limb, the 
extremity should be well raised up and a bandage firmly applied 
for some distance above the wound ; and if the wound is near a 
joint, a pad may be placed in the flexure of the joint next above 
the wound, and the joint firmly bent. 

If the bleeding continue, pressure should be applied in the 
course of the main artery of the limb, but this is only possible for 
the nurse if she is acquainted with its situation, and the spot at 

which pressure can be applied with effect. 
The finger or thumb may be used for this 
purpose, or some form of extempore tour- 
niquet, such as a handkerchief with a knot 
or some solid substance tied in ; the knot 
being applied over the artery and the ends 
tied tightly round. If the position of the 
vessel is not known, a handkerchief may 
be tied round the limb above the wound, 
and a stick inserted and then twisted round 
until sufficiently tight to stop the bleeding 
(fig. 47). An elastic bandage or india- 
rubber tube tightly wound round the limb 
Fig. 47.— Extempore Tourni- is often effectual (fig. 48). 

quet. Handkerchief and j n WO unds of the arteries of the upper 
extremity the main artery may be pressed 
upon in the groove on the inner side of the upper arm ; its course 
very closely corresponds to the seam on the inner side of the sleeve 
of a man's coat ; pressure must of course be made above the wound. 
In bleeding from an artery in the lower extremity pressure may 
be applied to the main vessel, the femoral artery. The spot 
chosen should be in the middle of the groin at the top of the 
thigh (fig. 49). 

After the bleeding has ceased, care should be taken, if the 
patient has to be moved to any distance, to keep the limb steady 
and raised on a pillow, but it should not be covered up, so that if 
the bleeding occurs it may at once be visible. 

Constitutional Symptoms. — Considerable loss of blood usually 
produces faintness, indicated by pallor and temporary loss of 
consciousness, accompanied by a feeble pulse. The mere fright 
caused by the sight of blood is sufficient to produce faintness in 
some people, but the condition is one favourable to the arrest 
of haemorrhage, because it reduces the power of the heart, and 
consequently diminishes the force of the blood stream. Imme- 
diate resort to stimulants is therefore unnecessary, or even harmful, 
and all that is requisite is to put the head low. 



WOUNDS AND THEIR COMPLICATIONS. 



157 



If the faintness proceed from the actual amount of blood lost, 
the pallor increases until the face is blanched, the breathing is 
sighing, and there is much restlessness ; the pupils dilate, and the 
extremities feel cold, a profuse perspiration breaks out, and the 
patient may be in danger of dying from syncope. The head 
should be kept lower than the body, and the extremities raised 
and kept warm. Stimulants should be given, and it may be 
necessary to inject stimulants, or even to use transfusion, a 





Fia. 48. — Extempore Tourniquet. 
Elastic Band. 



Fig. 49. — Mode of applying pressure 
to the Femoral Artery. 



method by which fluid of a suitable kind can be introduced into 
a vein, thus supplying the place of the blood which has been 
lost. 

After the immediate effects of the haemorrhage or shock have 
passed away, the patient sometimes becomes hot and flushed, 
with a quicker and stronger pulse, — a condition to which the term 
" reaction " is applied, and this stage will probably be intensified 
if much brandy has been given during the former period. 



158 A MANUAL OF NURSING. 

INFLAMMATION and ABSCESS.— Some wounds, especially 
if much lacerated and contused, or from the presence of some 
foreign bodies, or from other causes, do not heal readily ; the edges 
become red and swollen, the wound feels hot and painful, and 
these signs increase and spread into the surrounding parts. 

These four signs, redness, swelling, heat, said pain denote inflam- 
mation, and they are present in a greater or less degree in inflam- 
mation, wherever occurring, either in the external tissues or in the 
internal organs. 

Constitutional Disturbance. — In addition to the local signs in 
the wound there are often symptoms of affection of the general 
health. The patient complains of a sense of chilliness, headache, 
and pain in the limbs. The temperature is raised, the pulse quick, 
the skin dry, and the tongue coated. There is loss of appetite, 
thirst, turbid urine, and constipation ; in short there is f everishness. 
After a time the constitutional disturbance subsides, and the 
appearance of the wound alters, the redness, swelling, and discom- 
fort decrease, the inflammation terminates in " resolution," and the 
wound heals or becomes healthy : or the inflammation increases, 
giving rise to the further process of suppuration or the formation of 
pus or matter in the wound. The swelling and redness then increase, 
and the wound throbs and is very painful, and the constitutional 
symptoms may be considerable. The pus formation and discharge 
of matter is often accompanied by cessation of the acute pain, and 
the swelling diminishes. When matter is pent up in a wound or 
in the tissues, it causes very great suffering from the swelling and 
tension of the parts, and this is apt to occur in deep wounds 
which heal at the surface by first intention, while inflammation 
and suppuration are going on in the deeper parts. The matter 
is unable to find its way out, and collects in the interior, great 
fpain being experienced until the wound is re-opened, and the 
matter allowed to escape. Deep wounds should be made to heal 
from the bottom upwards. 

ABSCESS. — When a collection of matter forms in the tissues 
or organs, either as the result of wounds or spontaneously, it is called 
an abscess. This gives rise to the usual signs and symptoms of 
inflammation. The abscess may point or protrude at one spot, 
and then break through the tissues, or it may require to be 
opened by the surgeon ; the symptoms are commonly relieved as 
the matter is discharged. 

The character of pus or matter from an abscess or from an 
inflamed wound should be noticed by the nurse. Healthy or 
laudable pus is of yellowish colour and of a sweet, faint odour, 



WOUNDS AND THEIR COMPLICATIONS. 159 

and when coming from the surface of a granulating wound may 
contain streaks of bright blood from the healthy granulations, 
which easily bleed. The discharge from an unhealthy wound or 
abscess is greenish yellow or green, or dark brown or red, from 
decomposing blood, and the smell is unpleasant, offensive, or 
even putrid. 

Management. — A nurse should make herself familiar with the 
appearance of a wound which is becoming inflamed, or not doing 
well, and report to the surgeon. Such wounds require constant 
dressing and attention, and care must be taken to prevent the 
matter being confined by too close strapping. A bread or linseed- 
meal poultice will often suffice to relieve the tension and allow the 
matter to escape. The discharge should be carefully washed from 
the wound, and drainage secured by various means, such as 
insertion of strips of gutta-percha tissue, oiled silk, or drainage 
tubes. 

Antiseptic dressings may be required, and Iodoform powder 
sprinkled over the wound is often very effective. Strips of lint 
soaked in carbolic lotion, or some other antiseptic solution, may 
be laid over the wound, and the parts kept at rest, in bed, or by 
splints, according to circumstances. Moderate diet and aperients 
will help to control the feverishness. 

CELLULITIS is a form of inflammation which may attack the 
cellular tissue in the neighbourhood of a wound, and extends for 
some distance into the surrounding parts. The tissues affected 
become swollen and red, and the wound has generally an unhealthy 
appearance. The temperature usually ascends above the normal, 
accompanied by the customary symptoms of feverishness. 

ERYSIPELAS occurs in two forms. There is a superficial 
kind which only attacks the skin ; a rash of bright red colour 
appears around or near the wound, having a distinct margin. 
It spreads rapidly, and there is usually some swelling underneath. 
There is no limit to the extension of the rash, and it may disappear, 
and reappear suddenly in another part. Its natural term is 
generally eight or ten days. 

The other form of erysipelas is more severe ; it attacks the 
deeper parts as well as the skin, and is closely allied to cellulitis. 
There is more swelling and pain, and vesicles or blisters often 
appear on the skin containing clear fluid which soon becomes 
turbid. In erysipelas the constitutional symptoms are usually 
well marked. There is often a chill or rigor, with rise of tempera- 
ture and fever symptoms. The condition of the wound probably 



160 A MANUAL OF NURSING. 

changes, and an unhealthy appearance is visible before the attack, 
or a blush may be seen at or round the edges of the wound, and 
the discharges cease or change colour. 

Management. — The nurse should be on the look out for rigors 
or rise of temperature, and watch the wound carefully, especially 
if the patient is in the wards of an hospital, in order that the 
first sign of erysipelas may be detected, as the disease is highly 
contagious to others suffering from open wounds. 

It is usual to remove cases of erysipelas and cellulitis at once 
into separate wards to prevent the spread of the disease. 

Good ventilation and absolute cleanliness are essential. 

In cases of a low type nourishing diet and stimulants are 
required. 

There are many applications in ordinary use ; among the best 
being the application of collodion, or dredging the parts with 
flour. The greater number of cases get well, but among the 
intemperate, those of feeble constitution, or those suffering from 
kidney disease, the malady often proves formidable. Delirium, 
inability to take food, and a brown tongue, joined with great 
feebleness, are bad symptoms, and forebode a fatal termination. 

The disease is sometimes epidemic at certain seasons of the 
year, but it may break out in a ward and spread without any 
apparent reason. The nurse should notice if it makes its appear- 
ance first at any particular spot, or clings to any part of the 
building, since dirt, bad drains or decomposing materials are 
common causes of an outbreak. She should also remember its 
infectious qualities, and be careful to destroy dressings from these 
wounds, and not to employ splints or instruments for other patients 
which have been used in these cases. On the termination of the 
illness, all instruments should be thoroughly disinfected in strong 
carbolic solution, and the bed and bedding sent away to be 
disinfected (see Disinfection). 

Poisoned Wounds. — Slight cuts, abrasions, or wounds of any 
kind may become poisoned by the introduction of decomposing 
matter, or by the decomposition or foulness of their own dis- 
charges. 

A common instance is an ordinary " whitlow" The poisonous 
material enters at a small crack, or hang-nail, on the finger, and 
inflammation is set up in the deeper parts. Matter forms and 
perhaps can be seen as a yellowish-white speck deep under the 
skin. The affection is very painful, and unless the matter escapes 
or is relieved by an incision the inflammation may spread and 
affect the nail and the bone, destroying part of the finger. 

Inflamed Lymphatics. — As a result of whitlow or other 



WOUNDS AND THEIR COMPLICATIONS. 161 

poisoned wounds, inflammation of the lymphatic vessels and 
glands in the neighbourhood or above the wound is always to be 
suspected. The first sign of this is a faint blush running up the 
limb in the course of the vessels, with a feeling of pain and 
stiffness, and usually some constitutional disturbance. In the case 
of a whitlow the flush will be visible on the front of the fore-arm 
to the elbow, and along the inner side of the upper arm to the 
arm pit. Here there is often some tenderness and pain, and the 
lymphatic glands may perhaps be felt to be swollen, or the glands 
may be tender without any preceding blush. 

Management. — If the nurse is in charge of poisoned wounds 
of the extremities, she should be on her guard against inflamma- 
tion of the neighbouring lymphatics, and report at once to the 
surgeon. She should also be very careful of her own fingers, and 
touch the wound and discharges as little as possible, washing hei 
hands in carbolic or some antiseptic afterwards. These precau- 
tions may prevent her suffering herself. 

BLOOD-POISONING— PYEMIA.— In pyaemia the morbid 
material in the wound not only affects the lymphatics, but also 
enters the blood, producing a serious and often fatal disorder. 

Symptoms. — The onset is marked by a sudden and severe rigor, 
often lasting some time. The patient's teeth chatter, the bed 
shakes, and he becomes blue. His temperature is found to be 
above normal, and rapidly rises to 104°, 106°, or higher. After 
the shivering, profuse perspiration sets in, lasting some time, and 
the temperature subsides. These rigors are a great feature in the 
disease, and usually recur at intervals, often of twenty-four hours. 
The general condition of the patient rapidly becomes worse, and 
he gets pale and thin. During this time, or perhaps before, the 
wound has become unhealthy and offensive, and abscesses may 
appear in different parts of the body, either in the external tissues, 
in the joints, or in the internal organs. In acute cases death 
occurs in from two or three days to a fortnight. The more 
chronic last from two to six weeks or longer, and tnere is greater 
chance of recovery. 

Management. — The main predisposing causes to pyaemia are 
overcrowding, dirt, bad ventilation, and insecure drainage, some 
of which may be guarded against by the nurse ; and especial 
attention to these points is necessary in a ward where there are 
many discharging wounds. The nurse should comprehend the 
importance of a rigor, and take the temperature, administering 
some warm drink, and applying additional coverings. Later on 
her attention should be directed to complaint of pain in any region 

L 



162 A MANUAL OF NURSING. 

as perhaps indicating the appearance of an abscess. In chronic 
cases a water-bed is very desirable. The freest possible ventilation 
should always be secured. 

TETANUS or LOCKJAW.— This formidable malady is liable 
to attack patients suffering from wounds of any description, the 
slightest or the most severe, though it is perhaps more common 
after lacerated wounds. It is characterised by spasm and cramp 
in the muscles of the body of a most painful kind. 

Symptoms. — The early symptoms are important, and often 
slight in character. The first complaint is usually of a feeling of 
stiffness about the jaws and throat, so that eating is difficult, and 
the patient finds he is unable to open his mouth. Other muscles 
become affected, and a spasm comes on, in which the muscles, 
often the muscles of the trunk, become firmly contracted, and the 
face is drawn into a grinning expression. As the spasms increase a 
larger number of muscles become affected, the head is bent back, 
the body arched with the abdomen forwards, and if the spasm 
continue the breathing ceases, and the countenance becomes livid. 
If the spasm does not relax the patient may die of suffocation. 
In acute cases the spasms increase in severity and the intervals 
become less frequent, and death takes place by suffocation or 
exhaustion ; but the more chronic and less severe cases sometimes 
recover. 

Management. — Eecovery in cases of tetanus is obtained by 
very careful supervision, nursing, and feeding. It is important 
that the disease should be recognised at an early stage, and it is 
highly probable that the nurse will be the first to hear of the early 
symptoms. Sometimes gastric derangement and constipation 
precede the first stiffness about the muscles of the jaw, or the 
drawn expression of the mouth may be the first indication. The 
patient should at once be isolated and kept perfectly quiet, as the 
spasms are frequently started by the least noise, or even by a 
draught of air, or touching the bed. Feeding is of next import- 
ance, and should be carried on between the spasms frequently and 
gently. It is sometimes difficult on account of the closure of the 
mouth, but the fluid must be introduced through gaps between the 
teeth, or gaps must be made if necessary. Sleep should be 
encouraged as much as possible. 

ULCERS and ULCERATION. — An open sore is sometimes 
left as the result of injury, or inflammation of the skin or mucous 
membranes, or the loss of vitality in the affected part is due to 
some constitutional or local weakness. The sore or ulcer presents 



WOUNDS AND THEIR COMPLICATIONS. 163 

various appearances, and discharge of matter usually occurs from 
the surface. 

A healthy or healing ulcer is covered with small, red granula- 
tions, discharging yellowish pus, and is surrounded by healthy 
skin, presenting a bluish line at the circumference. The size of 
the ulcer diminishes day by day as the skin heals over. 

Iso further treatment than rest and simple dressing is required. 

Unhealthy ulcers are accompanied by a discharge of unhealthy 
pus, the skin round the margin appears inflamed, and the base is 
occupied by swollen granulations, or covered by a slough ; and the 
ulceration invades the surrounding parts. 

Special treatment is required for these ulcers, and under 
medical advice. 

Cold or callous ulcers are characterised by slow healing, and the 
margin is hard and white, and the surrounding skin brawny; the 
granulations are pale and flabby, and there is but little secretion 
from the surface. Stimulating applications are necessary, and 
attention to the general health. 

In the management of all ulcers, support by strapping and 
bandaging is required, and when the ulcer is situated in the lower 
extremity, a few days 1 rest in bed will often produce marked 
benefit. 

Malignant ulcers are of a cancerous nature, such as epithelioma, 
and rodent ulcers of the face. These attack persons in the more 
advanced periods of life, and can only be dealt with by operation. 

BUENS and SCALDS.— Destruction of the skin and soft 
parts of the body is caused by dry heat in burns, and by moist 
heat in scalds. The extent of this destruction indicates the 
severity of the burn, and in severe cases there is great nervous 
shock, with depression of the vital powers. The face is pale and 
drawn, the skin cold and clammy, the pulse fails, and there 
is immediate danger to life. 

Management. — When the patient is suffering from shock, the 
treatment must be directed to this before the local injury is 
attended to. He should be wrapped in warm blankets and placed 
near the fire, or covered up in bed, and hot bottles applied to the 
feet and surface of the body. Stimulants, hot beef-tea, or hot 
fluid of some kind should be administered. In the meantime a 
warm bath should be prepared, of sufficient size to enable the 
patient to be completely immersed. The water should be of a 
temperature comfortable to his sensations, and he may remain 
continuously in the bath until all severe symptoms have passed 
away (see Baths), 



164 A MANUAL OF NURSING. 

In the local treatment, after the charred remains of clothing 
have been gently removed, the burns may be dressed. One limb 
or part of the body should be dealt with first, the rest being 
covered up. If there are vesicles or blisters of large extent they 
should be snipped, and the fluid evacuated or soaked up with 
absorbent wool, but the skin should not be removed; small 
vesicles may remain uncut and be protected with cotton wool. 
The burnt surface may then be freely painted over with the 
flexile collodion of the British Pharmacopoeia, two or three times, 
or Carron oil (equal parts of lime-water and linseed oil) may be 
applied on lint. 

If these applications are not at hand, the surface may be 
freely dusted over with wheat flour, and enveloped in a thick 
layer of cotton wool, retained in position by a flannel bandage. 

In slighter cases, simple dressings of zinc ointment or lead 
lotion will suffice, and since the removal of dressings is always 
attended with severe suffering, they should be changed as seldom 
as possible. In the case of children or others of sensitive disposi- 
tion it is no uncommon practice for the surgeon to administer 
chloroform during the removal of the dressings. 

The scars left from burns are very disfiguring, and great 
contraction of the skin is apt to follow, producing various deformi- 
ties. Long after-treatment is required, and extension by means 
of splints of different kinds. 

Scalds of the throat in children require especial notice, as they 
are not infrequent amongst the children of the poor. They are 
commonly produced by attempting to drink boiling water from 
the spout of the tea-kettle. A scald of the mouth, fauces, and 
larynx results, giving rise to dangerous symptoms of difficulty of 
breathing from injury to the larynx. 

Management. — The child should be placed in a warm, moist 
atmosphere, by means of a covered cot, or surgical cradle, with a 
steam kettle near by, as for tracheotomy cases. In severe cases 
when the dyspnoea is urgent, tracheotomy may be required (see 
Tracheotomy), 



CHAPTER XL 

Fractures. 

Fracture by Direct and Indirect Violence— Simple, Compound, and 
Comminuted Fractures— Signs of Fracture— Union of Bone- 
Setting Fractures — First aid in Fracture. 

Management of Fractured Skull — Concussion and Compression of 
the Brain — Fractured Lower Jaw — Spine — Pelvis— Collar-Bone 
— Splints for Fractured Arm — Colles' Fracture — Thigh Bone — 
Bones of Leg— Patella — Plaster of Paris Case— Crutches- 
Compound Fractures — Sprains and Strains— Dislocations. 

Nature and Signs of Fracture. 

A bone may be broken by direct violence, as when the blow 
falls directly on the bone and fractures it at that point ; or by 
indirect violence, in which case it gives w r ay at some spot in 
between, the force being applied at one end, while the other is 
fixed. An example of the latter would be a fracture of the 
clavicle or collar-bone by a fall on the shoulder. 

A less common method of fracture is by muscular action, a 
powerful and sudden contraction of a muscle causing the bone 
into which it is inserted to break ; for instance a not uncommon 
example is fracture of the patella or knee-pan, by sudden con- 
traction of the powerful muscles in front of the thigh bone. 

When a bone is broken by indirect violence, it commonly gives 
way at the thinnest and weakest part. In jumping from a height 
the tibia is usually fractured at its w r eakest part, a point a few 
inches above the ankle joint. 

There are three kinds of fractures : — Simple, Compound, and 
Comminuted. 

Simple. — When the bone only is broken, and in one place. 

Compound. — When the bone is broken, and there is in addition 
a wound of the skin and soft parts communicating with the 
fracture. The wound may be caused by the same violence that 
produced the fracture, or the sharp end of the broken bone may 
be subsequently forced through the skin by the movements of the 



166 A MANUAL OF NURSING. 

patient, or by the careless handling of those who endeavour to 
assist him. 

Comminuted. — Where the bone is broken in more than one place. 

Signs of Fracture. — These are : — 

Loss of power in the limb. 

Distortion and swelling. 

Pain ; tenderness, and increased mobility when handled. 

Inequality in length between the injured and the sound limb 
when their measurements are taken. 

The hand placed on the bone at the injured part may detect 
some irregularity, and perhaps feel a grating sensation (crepi- 
tus), caused by the rubbing together of the fractured ends. 

Union of Bone. — A fractured bone is mended by nature on the 
same principles as an ordinary wound of the soft parts is healed, 
only the time required is considerably longer. To favour this 
process the ends of the bone must be brought close together and 
kept at rest. The blood which has been effused about the ends 
of the bones is gradually absorbed, and after about a week a soft 
material is formed around and between the ends of the broken 
fragments, which holds them together like splints, while the ends 
become glued together by the same material. This soft material 
is called " callus" and after the third or fourth week is hardened 
by the formation in it of bony substance, so that by the sixth or 
eighth week the fracture is united by bone and becomes solid. 
The time required for firm union varies according to the thick- 
ness of the bone, the larger bones taking longer than the slighter. 
Lumps of hard " callus " may often be felt about the seat of frac- 
ture when union is going on ; these are removed or smoothed down 
after a variable time, when the bones are united in a good position. 

Setting a Fracture. — In the treatment of fracture, the surgeon's 
first endeavour is to bring the ends of the bone as nearly as 
possible into their natural position, and then by means of splints 
and other mechanism to keep them so, and perfectly quiet. This 
having been done nothing remains than to wait and let nature 
complete the cure. In the greater number of cases, after union 
has taken place, the bone gradually regains its strength, so that 
finally it is as strong as before. In some few, especially debilitated 
subjects, the bones do not unite, and an " ununited " fracture is the 
result. This may also occur when the ends of the bone have not 
been brought sufficiently close together, or kept at rest ; but in 
these cases the bones more commonly unite at an angle, or in 
some other bad position, and deformity is the result, with impaired 
power of movement. 



FRACTURES. 167 



First Aid in Fractures. 

A person with a fracture, especially of the lower extremity, 
should remain, if possible, where he is until medical assistance can 
be obtained, the limb meanwhile being kept at rest. If it is 
necessary for him to be moved, the greatest gentleness and care 
should be exercised, and the fractured limb kept from further 
injury by firm support. If the upper limb be injured, it should 
be well supported by a sling in a comfortable position, and the 
patient should walk or be moved home. 

In the case of fracture of the lower extremity, some form of 
extemporised splint should be used to prevent movement of the 
broken ends and the possibility of a simple fracture becoming a 
compound fracture. For this purpose a stick, umbrella, or thin 
firm board tied on to the side of the leg by pocket-handkerchiefs 
will suffice. The injured and sound limb may then be tied 
together, and the patient removed on a stretcher or shutter. 

Management. — In cases of fracture of the lower extremities, 
the bed should be specially prepared for the patient, four or five 
deal boards about a foot wide being placed across the bed under 
the mattress, in order to prevent it from sinking in the middle. 

A soft mattress or feather bed must not be used, but one of good, 
firm horse-hair or well-stretched sacking. 

It will be necessary for the nurse to undress the patient, and 
she should be practically acquainted with the right method. 

The boots must be removed with great care, and while with- 
drawing the boot with one hand, the other should be employed to 
steady the limb at the ankle. If there is any difficulty the boot 
should be cut down one side. Before removing stockings the 
garters must be loosened ; braces should be unbuttoned in front 
and behind. 

If there is any difficulty in removing the trousers, or if the 
thigh bone is fractured, it is better to cut down the outside seam, 
which can be easily repaired. 

On taking off the coat it is better to remove the sleeve from the 
sound limb first. 

The patient may be undressed either on the bed or on the 
stretcher on which he was carried : before placing him in bed the 
bed-clothes should be well turned down, and then he should be 
lifted on, a person standing on either side of the bed to do so. 
If it is necessary to wait any time for the setting of a fracture, the 
leg may be supported at the sides by sand-bags or some substitute* 
the bed-clothes being kept off by a cradle. 



168 a Manual of nursing. 

Special Fractures, 

FRACTURE OF THE SKULL.— A blow or fall on the head 
may fracture the roof of the skull by direct, or the base by indirect 
violence. If the roof is fractured, the scalp will probably be 
wounded and the fracture be compound. The fracture may take 
the form of a slit or fissure, or the bone may be forced in, causing 
a depression. 

In fracture of the base of the skull, there may be merely signs 
of a blow on some part of the head. 

Symptoms — Concussion of the Brain. — In some cases of 
severe blows on the head, whether the skull be fractured or not, 
there is evidence of concussion of the brain. This may be slight, 
and is accompanied by pallor of the face and feeble breathing. 
There is more or less unconsciousness, but the patient will often 
answer questions, though with difficulty and in monosyllables. The 
symptoms are immediate ; vomiting is very common, and there is 
confusion of thought for some time after, with perhaps loss of 
memory for events occurring at the time of the accident. Headache 
is usually severe and persistent, and there is often subsequent 
drowsiness. After a good sleep the patient frequently awakes 
much better. 

Management. — Absolute quiet and rest in bed for some time. 
The feet and legs should be kept warm, and cold may be applied 
to the head. Afterwards the diet should be light and unstimula- 
ting, and the bowels relieved by aperients. 

FRACTURE OF THE BASE OF THE SKULL.— The 

symptoms of compression are usually present, and in addition there 
may be bleeding from the mouth, nose, or ears, or a discharge of 
watery fluid from the ear. 

Compression and Injury of Brain. — When the roof of the 
skull is broken in and depressed, the brain and membranes under- 
neath are injured and the symptoms are more severe, or blood 
may be effused within the skull, causing pressure on the brain. 

Symptoms. — The symptoms are those of compression, of which 
the following are the most important. There is complete loss 
of consciousness, the breathing is slow and laboured and perhaps 
stertorous, the pulse is slow, the bladder paralysed, the pupils 
dilated or unequal, — in short a condition of " co?na." These 
symptoms may come on at the time of the accident, or may 
supervene after an interval of consciousness. In any case they 
are of very grave import. When the bone is depressed, an opera- 
tion is performed by the surgeon to raise the bone and remove 



FRACTURES. 



169 



the fragments, which may be pressing on and irritating the brain, 
or " trepanning " may be necessary, a process by which a hole is 
made through the roof of the skull to facilitate the operation. 

Management. — The patient should be put in a darkened room 
and kept quiet ; if unconscious, all the attention required in such 
cases will be necessary (see Coma). The nurse should be watchful 
for anything in the form of a convulsive seizure, for returning 
consciousness, or for any evidence of local paralysis. When 
fracture of the base is suspected, the pillow should be examined 
for evidence of discharge from the ears. If any operation has to 
be performed, the head will probably require shaving. 

After the immediate effects have passed off, the temperature 
should be noticed, or if there is other sign of fever, indicating 
the onset of meningitis (see Meningitis), 



bandage 



is convenient for 



FRACTURE OF THE LOWER JAW.— The person will 
have difficulty in opening his mouth and speaking. There may 
be bleeding in the gums, or looseness of the teeth, near the 
fracture. 

Management. — A special form of 
this fracture, and the nurse should be 
able to make it. It is called the four- 
tail chin bandage, and consists of a 
yard and a half of calico three or four 
inches wide, with the ends slit down 
the middle to within three inches of 
the centre. A hole or slit should be 
made in the centre about an inch from 
the border, just large enough to receive 
the chin. To apply the bandage, the 
chin is first placed in the central slit 
with the narrower side in front, the 
two upper tails are carried back and 
fastened round the neck, while the 
lower ones are tied on the top of the head (fig. 50). 

Fluid nourishment should be given for some time after fractured 
jaw, as mastication is difficult. 

FRACTURE OF THE SPINE.— The symptoms of fracture of 
the vertebras, with displacement, depend on the amount of injury 
to the spinal cord. Injury to the cord high up in the neck is 
often immediately fatal; if lower down, the symptoms are those of 
paraplegia, and the complications and management will be similar 
(see Paraplegia), 




Fig. 50.— A, Four-tailed Band- 
age for Fracture of the Jaw ; 
X, Aperture for Chin. 



170 A MANUAL OF NURSING. 

When the vertebrae in the neck are fractured, the greatest care 
should be exercised to keep the head from any sudden movement; 
it is advisable to place the patient at once on a water-bed. 

FRACTURE OF THE RIBS.— Pain is felt at the seat of the 
fracture, especially on movement or taking a deep breath, and 
coughing or sneezing are particularly painful. Great relief is ex- 
perienced from firm pressure, which helps to control the movements 
of respiration. 

Management. — A flannel roller eight or ten inches wide should 
be firmly bound round the chest once or twice, and then stitched, 
or a broad piece of strapping may be first applied half round the 
chest on the injured side. 

Complications. — Injury to the pleura and lung by the broken 
ends of the bone may occur, causing difficult and rapid breathing, 
with much pain, owing to inflammation of the pleura. Pneumonia 
or inflammation of the lung may set in, in which case there is 
troublesome cough with expectoration, often of blood-stained 
phlegm, rapid breathing, and general signs of fever (see Pneu- 
monia), 

FRACTURED PELVIS is usually the result of very severe 
violence or crushing, so that the internal organs often suffer 
damage, especially the bladder. The nurse should be careful to 
notice if any urine is passed after the accident, and should save it 
in order that it may be examined to see if it contains any blood. 

FRACTURED COLLAR-BONE is a common accident from 
falls on the shoulder. The patient is usually inclined to support 
the elbow of the injured side with the other hand, and bends the 
head to the injured side. 

Management. — There are many methods for setting a broken 
collar-bone, but the nurse should prepare the following apparatus : — 
A wedge-shaped pad of some firm material, of moderate size, to 
place in the arm-pit. Bandages to confine the arm to the side, 
and a sling to support the fore-arm. The bandages may be best 
kept in position by stitching them together. 



Fractures of the Upper Extremity. 

FRACTURED HUMERUS.— Short splints or well-padded 
Gooch splints are sometimes used, or a short external with an 
angular internal splint may be applied so as to fix the fore-arm, 
the arm being put in a sling. 



FRACTUEES. 171 

FRACTURED ULNA AND RADIUS.— Two side splints of 
sufficient length to extend from the elbow to the fingers are 
required; the inner one should be shortened so as not to press at 
the bend of the elbow when the limb is flexed. 

COLLES' FRACTURE, or a fracture of the lower end of the 
radius, is very common, and may be treated with two side splints, 
or by a special internal splint, of the pistol-shape, or one provided 
with a hand-piece. 

Management. — In attending to fractures of the upper extremity, 
the nurse should be careful to notice if there is any undue swelling 
or blueness of the hand, or if great pain and numbness is com- 
plained of by the patient, as the bandages may require loosening. 
If unable to consult the surgeon at the time, it would be better to 
loosen or cut up part of the bandage than risk gangrene from tight 
pressure. 

Strapping or bandages underneath the splints are to be avoided, 
as liable to create undue pressure and interference with the 
circulation, or pressure of the splint at the bend of the elbow may 
cause the same discomfort. 

The time required for a fracture to remain in splints varies from 
three to six or more weeks, according to the size of the bone or the 
severity of the accident. It is often necessary to remove the splints 
during the treatment, and gently move the joints in order to 
prevent stiffness. In many cases of fracture, if this precaution is 
not taken, and the splints are kept applied for a long time, a 
troublesomely stiff joint ensues, which may take as long to remedy 
as the fracture itself. In fracture of the clavicle or injury to the 
upper arm, the shoulder joint, and in fractures of the arm the 
elbow and wrist joints, require to be moved. After removal of 
splints it is safer to keep some support on the limb, and the arm 
should still be kept in a sling ; gentle and gradual movement being 
practised until the bone is firmly consolidated and strength 
restored. 

Fractures of the Lower Extremity. 

FRACTURE OF THE THIGH-BONE.— From the action or 
contraction of the powerful muscles of the thigh there is often 
considerable shortening of the limb in this fracture, and in addition 
to splints an apparatus for pulling down the lower fragment is 
useful. This is managed by hanging a weight on to the lower leg, 
to which method the term " extension " is applied. 

Apparatus required. — A long, padded splint, Liston's or other, 
of sufficient length to extend from the arm-pit to a few inches 



172 A MANUAL OF NURSING. 

below the foot. There should be a hole cut for the outer ankle, and 
the splint should be provided with a cross foot-piece. Strapping, 
broad bandages, flannel, and calico, a broad binder to fix the splint 
to the body, and several pads of different sizes are necessary. 

The extension apparatus is fixed on the leg by means of a 
"stirrup" This consists of a flat piece of wood, two to three 
inches square, with a hole bored through the centre, and a strong 
piece of strapping one and a half inches wide, and about a yard 
long. The wood is placed in the middle of the strapping, which 
is fixed to it by another strip of plaster bound round it, and a hole 
is bored through the middle. A piece of cord is passed through 
the hole, and to this a weight of several pounds is attached (fig. 51). 

The fracture is put up as follows : — The strapping is heated and 
applied on either side of the leg as high as the knee, avoiding 
the ankle, around which some wadding may be wrapped. A 
flannel bandage is then carried up from the foot, over the strapping, 
to the knee. Firm, steady traction is then used to draw down 




Fig. 51.— Extension by Weight and Pulley. 

the lower fragment into position, and while this is kept up by an 
assistant, the surgeon applies the long splint to the outer side of 
the leg. The cord can then be passed through the hole in the 
stirrup, and as heavy a weight as necessary fixed on, and hung 
over a pulley or bar at the foot of the bed. Extension is by 
this means constantly kept up on the lower fragment, and the bones 
maintained in position. 

Another method of extension, but not so commonly used now, 
as being far less comfortable, is by means of the "perineal band" 
The upper end of the long splint is provided with two holes. 
A soft handkerchief or padded band of lint, the perineal band, is 
passed between the thighs, and the two ends passed through the 
holes in the top of the splint. After the splint has been bandaged 
to the leg, extension is put on the lower fragment, and at the 



FRACTURES. 



173 



same time the perineal band is tightened, and firmly tied at the 
top of the splint. It is advisable to cover the perineal band with 
oiled silk, as it is liable to get soiled with the excretions. The 
splint may be kept straight by sand-bags, and a cradle should be 
placed over the broken bone. 

In the treatment of fractured thigh-bone in children, it is 
often necessary to put the sound limb in a long splint also, to 
prevent them rolling over and moving about; they may also 
require to be tied up to the head of the bed by a band round the 
waist, to prevent their slipping down towards the foot, and so 
removing the extension. 

FRACTURE OF THE LEG.— Either one or both bones may 
be broken, the most important being the tibia, the larger of the 
two. When the bone is broken just above the ankle-joint there 
may be considerable displacement of the foot to one or other side. 

Splints. — Fractures of the leg-bones may be put up in a back- 



splint and two side-splints. 
The back-splint should ex- 
tend from above the knee to 
the foot, where there should 
be a foot-piece. The leg is 
first bandaged into the back- 
splint, with a good pad under 
the Tendo Achillis above the 
heel, to keep pressure off the 
heel. The foot is bandaged 



5£- 



<*x? 




Fig. 52.— Fracture Cradle, 
a, board ; b, c, iron rods. 



to the foot-piece, and the bandage carried all the way up, or a 
space may be left free at the seat of fracture. The two side- 
splints may be fixed on by a band and buckle above and below, 
the whole leg being suspended by straps or bandages to a cradle 
and allowed to swing, in which position it is most comfortable 
(fig. 52). 

Management. — Great discomfort is felt by the patient when 
the heel rests on the splint ; the constant pressure interferes with 
the circulation, and an ulcer or sore place frequently forms which 
interferes with the treatment ; the same trouble may be produced 
by too great pressure on the prominent ankle bones. This is 
avoided by careful adjustment of pads in suitable positions. 

After applying neatly to the lower limbs bandages which have 
to remain on for some time, it is a good plan to starch them over 
and let them dry, by which means they are kept tidy and in 
position. The leg is usually kept in splints from four to six 
weeks. 



174 A MANUAL OF NURSING. 

FRACTURED PATELLA.— The knee-pan is often broken by 
the sudden contraction of the powerful muscles in front of the 
thigh. This accident is generally accompanied by swelling and 
effusion into the knee-joint at the time, or soon after, and it is 
often necessary to wait for a while, and apply cold lotions to reduce 
the swelling, before the bandages can be applied. 

Management. — The patient may be propped up in bed with the 
leg raised on pillows or a rest, in order to relax the front muscles. 

There are many methods of treating this fracture. A back- 
splint may be applied, and two pieces of strapping or an elastic 
bandage placed above and below the fragments, to bring them 
together. After remaining on the splint for six or more weeks, 
the limb has to be encased in some firm support, and kept from 
bending at the knee-joint for several months longer, before the 
fracture is sufficiently united to bear any strain, and resist 
stretching. 

After-treatment of fractures of the lower extremity. It is a 
common and convenient practice to remove the splints in cases of 
fracture before the bone is actually consolidated, and to put 
them up in some firm support, so that the patient can go about 
with crutches or sticks until the cure is complete. 

The substances in common use are starch, gum and chalk, and 
plaster of Paris. The latter has many advantages, and may be 
applied as follows. 

Plaster of Paris Bandage. — The plaster should be the fine, 
white powder used by modellers ; the bandages of very loosely 
woven lint. The dry powder should be rubbed into the meshes 
of the bandage on both sides, with the palm of the hand, and the 
bandage rolled up. The limb may be first evenly bandaged with 
a flannel bandage. The plaster bandages should be placed in a 
basin of water containing some of the powder for a few minutes 
before using, and when thoroughly wetted may be applied over 
the flannel bandage evenly, as far as possible without " reversed 
turns," each fold overlapping the one below. Some of the wet 
powder may be rubbed in between each layer, and two or three or 
more layers of bandage may be used, according to the desired 
strength and thickness of the case. 

The plaster will have set in five or ten minutes, and should then 
be allowed to dry. 

The plaster bandage can be removed when desired by unwinding 
the bandages, or if too thick for this, the dilute hydrochloric acid 
may be rubbed along one side for a few minutes, after which the 
bandage may be cut down by scissors. 

Crutches. — After a fracture of the lower extremity, on first 



FRACTURES. 175 

getting up the patient is too weak to move about, and in his first 
attempts to walk he will require the use of crutches, or two sticks. 
The leg should be supported in a sling passing under the foot and 
round the neck, the crutches being only just of sufficient length to 
enable the patient, standing on the sound leg, to raise the injured 
one off the ground. The cross-bar for the arm-pit should be well 
padded with soft material, to prevent undue pressure on the nerves 
of the arm. The end is then covered with a cap of leather or cloth, 
to prevent it from slipping on the ground, and the person should 
be warned against using them on a slippery floor. Great care 
should be exercised when a patient in a weak condition first uses 
crutches. 

Compound Fractures. 

COMPOUND FRACTURES.— It is very important that these 
should be converted into simple fractures as soon as possible by 
the rapid healing of the wound. If the wound is slight, a piece 
of lint, soaked in carbolic oil, or covered with collodion, is a good 
application. 

Where there is more damage and much effusion of blood into 
the tissues, a water-dressing or poultice should be applied, or the 
wound may be dressed antiseptically (see Antiseptic Dressings). 
"Where the wound heals readily the fracture will unite as well as 
simple fractures. 

Splints. — The surface wound often prevents the use of ordinary 
splints, and an interrupted splint is useful. In splints of this kind 
a gap is left at the part required, the place of the wood being 
taken by a curved piece of iron. The interruption can be made 
at any place, and the wound can then be dressed without disturbing 
the splints. 

In very severe accidents, where there is so much damage to the 
limb that there is no chance of saving it, and gangrene would be 
likely to supervene, amputation is necessary (see Amputation). 

Sprains and Dislocations. 

SPRAINS and STRAINS are the result of the forcible over- 
stretching of the muscular and ligamentous tissues. This very 
commonly occurs in the neighbourhood of a joint such as the 
ankle or wrist, from the effect of a wrench or a twist. Acute 
pain is then felt at the moment, sufficient to produce temporary 
faintncss or sickness, and the part becomes rapidly swollen, and 
hot. In a few days the swelling gradually subsides, and usually 
some discoloration appears under the skin, due to effusion of 



176 A MANUAL OF NURSING. 

blood from the rupture of small blood-vessels, the colour changing 
after a time from red to various shades of greenish blue and black. 
In many cases of strains and sprains in which the immediate 
swelling and pain soon subside, a long time elapses before the 
patient is able to move the parts freely. 

Management. — Injuries to joints should be examined as soon 
as possible by the surgeon, in order that he may determine 
whether there is any further damage than a strain of the soft 
parts, since the subsequent swelling makes it difficult to be certain 
in some cases as to the extent of the injury. 

In severe cases a splint may be applied with advantage, and in 
any case perfect rest is necessary for a time. 

Hot fomentation, or bathing with hot water, may be employed, 
or cold applications and evaporating lotions may allay the pain. 
A bandage exercising moderate pressure will sometimes prevent 
excessive swelling, and the parts may be subsequently rubbed with 
liniment, or douched with cold water, with advantage. 

A bandage should be worn for some time after the patient has 
begun to use the joint. 

DISLOCATIONS occur as the result of violence by which there 
is a displacement of the bones at a joint : they are usually accom- 
panied by some tearing of the ligaments or muscles which surround 
the joint. 

There is more or less deformity, and the movements of the joint 
are impossible, or much interfered with, and are accompanied by 
great pain. 

Dislocation may occur at almost any of the joints, but some are 
more easily displaced than others, owing to the shape of the arti- 
cular surfaces. 

A considerable amount of technical knowledge is required to 
recognise the nature of these injuries, and they should be seen by 
the surgeon as soon as possible, in order that they may be rectified 
or " reduced " at an early stage. Swelling commonly succeeds 
these accidents, and after reduction it is necessary to keep the 
parts at rest by bandages and splints. 

Management. — The nurse should be prepared with splints, and 
may have ready in addition, for the operation of reduction, 
bandages, jack-towel, and starch powder to dust over the part 
where pressure will have to be applied. 

In dislocation of the hip, or old dislocations, or other cases 
where there is difficulty in reduction, it is usual to administer some 
anaesthetic to relax the muscles and prevent pain. 



CHAPTER XII. 
Operations and Special Surgical Cases. 

Preparing Patient for Operation — Operation Room and Table — 
Management of Patient after Operation — Hemorrhage after 
Operation. 

Management of Hare-Lip — Cleft Palate — Tracheotomy Cases — 
Gangrene — Amputations — Retention of Urine — Catheters — 
Stone in the Bladder — Lithotrity — Lithotomy — Fistula — Piles 
— Hernia — Strangulated Hernia — Ovariotomy. 

Operations, 

Preparing Patient for Operation. — The nurse should see that 
the patient's clothes are properly arranged beforehand, and he 
should be dressed as lightly and loosely as possible, with due 
regard to warmth. All bands about the neck and waist should 
invariably be loosened, and the part to be operated on may 
either be left uncovered, or just covered by a loose article of dress, 
which can be thrown off in a moment. The dressings should also 
be removed if there is a wound, and this simply covered with lint. 
The patient must not be allowed to get cold, and should wear a 
flannel dressing-gown over the night shirt, and a pair of warm 
stockings and slippers. The loose garments can then be easily 
turned back from the part to be operated on, which may be 
surrounded with carbolised towels, and a macintosh arranged to 
prevent the blood soaking through and soiling the clothes. 

The nurse should ascertain that the patient is thoroughly clean 
before the operation, and the part to be operated on may be 
washed with soap and water, sponged over with carbolic lotion, 
and dried immediately beforehand. The hair of the head should 
be arranged so as not to interfere with the surgeon, when the 
part to be operated on is the neck, or in its neighbourhood. 

Before operation, the urine of the patient should be saved in 
order that it may be examined, and in the morning a free evacua- 
tion of the bowels should be obtained, if necessary by an enema, 
and an aperient given over night. 

When chloroform or ether has to be administered, it is import- 

M 



178 A MANUAL OF NURSING. 

ant that the patient should not take any solid food for at least 
four hours beforehand. The last meal should be a light one of 
meat-soup or beef-tea, with a little stimulant if necessary. A full 
stomach at the time of receiving the anaesthetic is a source of 
danger to the patient, and will result in troublesome vomiting and 
discomfort. False teeth must be removed prior to operation. 

Operation-Room and Operation-Table. — The temperature of 
the room should be from 65° to 70° ; there should be a fire and a 
large kettle containing boiling water. The operation-table should 
have a folded blanket upon it, and a pillow or two \ a macintosh- 
sheet being placed over the part of the table at which the 
haemorrhage will occur, and a large tray of sawdust on the ground 
to catch the blood. 

The nurse should have the following requisites always in 
readiness : — 

(1) Extra blankets and macintosh-sheets. 

(2) Towels. 

(3) Hot and cold water. 

(4) Bandages and strapping plaster. 

(5) Lint and cotton- wool. 

(6) Oiled silk. 

(7) Basins, large and small. 

(8) Bucket. 

(9) Sponges. 

(10) Oil and Vaseline. 

(11) Scissors and dressing-forceps. 

(12) Pins and safety-pins. 

(13) Syringe. 

(14) Brandy and ammonia. 

The duties of the nurse in the operation-theatre are various; 
she may be single-handed, but more often there are others assist- 
ing, and to each is allotted her special task. In any case she must 
be attentively on the look-out to be ready with anything that may 
possibly be required. Her duty may be simply to attend to the 
sponges, having a clean one always ready to hand, and a bowl 
to contain the soiled ones. Each sponge should be washed in 
warm carbolic solution, and well wrung dry before it is handed to 
the surgeon, or the wound becomes filled with water. All dress- 
ings an^pUnts^ &&§a d 
of the operation, anda^^ %mo 
th$, 







Ifi 



OPERATIONS AND SPECIAL SURGICAL CASES. 179 

the blood, clean the .surrounding parts which have been soiled, and 
then dry them. In sponging, the movement should be towards 
the wound. Whilst the operation is being performed, the patient's 
bed must be prepared, and if he should have to remain there 
some time a " draw-sheet M must be placed over the ordinary sheet 
where the pelvis will lie. Another draw-sheet and a macintosh- 
sheet must be placed ready for the patient so that they may i 
beneath the wound and soak up all discharges. In cold weather 
the bed must be warmed with a hot bottle. 

Management of the Patient after an Operation. — In moving 
the patient from the operation-table, especially if not quite 
recovered from the anaesthetic, he should not be suddenly rai£ 
into a sitting posture, lest faintness be induced. He should be 
carried out and placed in bed, and it is then the nurse's duty to 
watch him carefully, and see that he has plenty of fresh air ; if 
he is sick the head and body shoidd be slightly raised or turned 
on one side. But if there is unusual depression, faintness, or diffi- 
culty in breathing, the attention of the surgeon should be requested. 

WTien the immediate effects of the operation have passed off, 
the patient should be kept as quiet as possible, and as a rule 
nothing should be given by the mouth except a little ice or iced 
water for some hours ; after that, if there is no nausea or sickn< 
a small quantity of milk or beef-tea may be administered. If 
there is troublesome sickness, only a very small quantity of fluid 
should be given at one time, either iced soda-water, effervescing 
drink, or iced champagne ; and a mustard plaster may be applied 
to the pit of the stomach. Ice should be given in moderation, 
not too frequently, nor for too long a time. When there has been 
much haemorrhage, or when the operation is followed by great 
faintness or collapse, the nurse should ask for instructions as to 
the administration of stimulants. 

Haemorrhage after Operations. — Intermediate or Reactionary 
haemorrhage is that occurring soon after an operation. Small 
vessels which did not bleed at the time of the operation sometimes 
begin to do so when the patient becomes warm in bed, and as he 
recovers from the depressing effects of the chloroform or the opera- 
tion. In order that the nurse may watch the part that has been 
operated on, it should be left partially uncovered, or if this is not 
possible, the dressings and parts around should be examined every 
now and then. After the amputation of a limb, a cradle should 
be placed over the stump, and the bed-clothes partially turned aside. 

The nurse should learn to distinguish the oozing of blood-stained 
dfehargesi soaking ; tfe¥ough- the dressings J and bandages from fresh • 
blood. 



180 A MANUAL OF NURSING. 

In the former the discharge is thin, and dull in colour, and 
extending beyond this is a margin of a still fainter tint. 

Fresh blood is bright red and extends more quickly, and 
the stain is throughout of a brilliant colour. This reactionary 
haemorrhage may come on soon after the operation, but perhaps 
not for some hours, or during the night. The patient may become 
aware of the haemorrhage by feeling something warm trickling 
down, or he may notice that the bed is getting wet, or he may 
suddenly feel faint. Patients who have just been operated on must 
be very carefully attended during the night, and if there is any 
suspicion of bleeding, the dressings, grooves of the splint, and the 
surrounding parts should be examined, and left exposed or very 
lightly covered. If there is bleeding, the surgeon should be 
summoned, and if this becomes alarming before his arrival, the 
part should be well raised and exposed to the air. 

If this is insufficient, pressure must be applied with the fingers 
or thumbs to the main vessel until help arrives, or other means 
for arresting haemorrhage must be adopted (see Haemorrhage). 

Secondary or Recurrent haemorrhage is the term applied 
when bleeding occurs subsequently to the separation of the 
ligature that has been used to secure a vessel, or it may be due to 
sloughing of the wound and consequent opening up of vessels. 
In such cases the bleeding may be very rapid and severe, and 
place the patient's life in jeopardy. Tourniquets, pressure on the 
bleeding spot, or any of the means described under "Haemorrhage," 
must be used until assistance can be obtained (see Haemorrhage). 

In cases where secondary haemorrhage is expected, it is a useful 
precaution for the surgeon to mark with ink the spot at which 
pressure should be applied, and the nurse should receive directions 
as to the best means of applying it. 

A tourniquet may be kept loosely adjusted, which can be 
tightened up at once if necessary. 

Special Surgical Cases, 

HARE-LIP and CLEFT PALATE.— These deformities date 
from birth, and may exist separately or together. In simple hare- 
lip there is a cleft in the upper lip on one side of the middle line. 
When double there is a fissure on each side of the middle line, 
and one often extends into the nostril. Cleft palate may be 
associated with hare-lip or exist independently. On looking into 
the mouth a fissure or cleft is seen in the palate at the back 
part, so that the cavity of the nose and mouth are placed in 
communication. 



OPERATIONS AND SPECIAL SURGICAL CASES. 181 

The operation for hare-lip is usually performed during infancy 
or in childhood, the edges of the cleft being united and held 
together with a pin ; a piece of strapping, broad at either end and 
narrow in the middle, is next adjusted, while the cheeks are 
pinched together with the thumb and finger, so that the broad 
part adheres to either cheek and the narrow portion covers the 
upper lip. The object is to prevent traction on the wound, and 
allow the edges to heal. The baby should be fed with the spoon 
for a time. At the end of two or three days the pin will be 
removed and the strapping re-applied. 

The operation for cleft palate is performed at a later date. It 
is difficult to obtain a favourable result, and the patient requires 
great care afterwards. Xo speaking should be allowed, the mouth 
being kept shut as far as possible, and fluid nourishment adminis- 
tered for a time. 

TRACHEOTOMY, or the operation of opening the windpipe 
and inserting a tube, is performed when there is obstruction to the 
passage of air through the larynx, and when the patient is in 
danger of suffocation. 

Management of the patient after tracheotomy is usually 
entrusted to a thoroughly experienced and trustworthy nurse, and 
a favourable result can only be obtained when this after-treat- 
ment is well carried out, particularly in the case of children, in 
whom the operation is far more often required. 

There are three main points in the after-treatment which require 
special notice : — 

(1) To keep the tube clear. 

(2) To prevent the access of cold air. 

(3) To feed carefully. 

1. To Keep the Tube Clear. — The nurse should be familiar with 
the ordinary form of tracheotomy tube in use, — the silver double 
tube. The outer tube is provided with a slit on each side of the 
guard, through which a piece of tape is passed long enough to go 
twice round the neck. The outer tube is thus secured in the 
wound, the inner tube being taken out and cleaned as often as is 
necessary (fig. 53). 

When removing the inner tube, the finger and thumb of the 
other hand should hold the outer tube by the guard and gently 
press it towards the wound ; the surfaces of the inner tube may 
be oiled with advantage. 

In cases of diphtheria, the sticky mucus, or portions of membrane, 
are apt to block up the tube, and constant cleaning is required 



182 



A MANUAL OF NURSING. 



or the patient will suffocate. The process of cleaning may be 
managed by means of a feather dipped in solution of bicarbonate 
of soda (fifteen grains to the ounce), the feather being turned 
round as it is withdrawn. If this is insufficient, the inner tube 

must be removed and soaked 
in the solution, or in boiling 
water, until the tenacious 
material is got rid of. 

If there is any difficulty, 
and the breathing does not 
seem to be satisfactory, the 
surgeon should be immedi- 
ately summoned. If pieces 
of membrane be detruded 
they should be saved for 
inspection. 

2. To Prevent the Access of 
Cold Air, — A good method is 
to make a tent outside the 
bed with curtains, enclosing 
its three sides. The open 
side may face the fire, and a 
bronchitis kettle should be 
kept boiling on the hob. 

The temperature inside the 
cot must be registered by a 
thermometer, and not allowed 
to become unduly heated. Failing this arrangement, flannels 
wrung out in hot water should be applied over the tube, and 
constantly changed. 

3. The Feeding of young children who have had tracheotomy 
performed for diphtheria requires great care and attention. Their 
powers are much exhausted by the disease, and it is difficult to 
persuade them to take nourishment, as swallowing is often painful ; 
or the amount taken at a time is so small that they have to be 
constantly disturbed in order that they may receive sufficient food 
to keep up their strength. An infant's power of swallowing is 
generally interfered with by the tracheotomy-tube, and the milk 
sometimes finds its way down the trachea into the lung, and sets 
up pneumonia. 

In cases where there is great exhaustion, and sufficient nourish- 
ment cannot be administered by the mouth, feeding may be 
managed through the nose. For this purpose a soft india-rubber 
catheter, No. 4-No. 6, should be passed through the nostril, and 




Fig. 53.— Tracheotomy Tube ; tapes 
tied in. 



OPERATIONS AND SPECIAL SURGICAL CASES. 183 

on to the back of the pharynx ; it should then be pushed on 
and will find its way into the gullet without much difficulty. 
The milk or fluid can be administered by a syringe or funnel 
through the tube. By this means four to six ounces can be given 
at a time, and the child allowed to sleep longer without disturb- 
ance. 

GANGRENE, or mortification of a part, may supervene as the 
result of inflammation, or may be produced by cold, as in frost-bite, 
or by the effect of pressure and consequent stopping of the circula- 
tion in the part, as is the case in bed-sores. 

There are two forms, the moist gangrene and the senile or dry 
gangrene. 

Moist Gangrene. — After severe accidents in which the damage 
to the soft parts is extensive, the inflammation may be violent and 
result in moist gangrene. The appearance of the inflamed part 
alters, the red colour becomes livid, mottled, or greenish black ; 
the skin blisters, and a thin, discoloured, watery discharge 
exudes, and a foetid odour is perceptible. The sense of pain 
and touch becomes lost when the part is dead or mortified. 
Under favourable circumstances the mortification or gangrenous 
inflammation ceases to spread, and the dead part becomes 
marked off from the living by a line of healthy inflammation 
called the line of demarcation. The dead part subsequently 
separates itself naturally from the living, or is removed by the 
surgeon. 

During the process of gangrene the patient exhibits general 
symptoms of constitutional disturbance, and in severe and 
unfavourable cases loses appetite and strength ; the tongue 
becomes dry and brown, and the features shrunken and pale. He 
wanders at night, and does not sleep, or he becomes unconscious, 
and gradually sinks from the effects of exhaustion. 

Senile, or Dry Gangrene, attacks old people in whom the blood- 
vessels have become diseased, so that the blood-supply is impaired. 
It is more liable to occur in parts that are far removed from the 
heart and where the circulation is sluggish, as in the feet, fingers, 
or ears. One of the toes is the part most commonly affected, it 
becomes numb, cold, pale, and shrunken, and then gradually turns 
black, dies, and shrivels. The process is often very painful, and 
the powers of the patient may be unable to withstand the accom- 
panying exhaustion. 

Management. — The nurse should direct her attention to the 
dressing or local treatment of the gangrenous part, and maintain 
the powers of the patient by giving nourishment or stimulants 



184 A MANUAL OF NURSING. 

constantly, as directed by the medical attendant. In the moist 
form of gangrene where there is much sloughing, and consequently 
great fcetor, poultices or hot moist applications are best avoided, 
and some antiseptic, such as carbolic lotions or lint, used, or 
iodoform, or powdered charcoal may be dusted on, and the part 
swathed in oakum or charpie. 

In senile, or dry gangrene, a small poultice, charcoal or yeast, 
may be applied, or an opiate lotion used, or the part painted over 
with balsam of Peru, and the limb well surrounded with cotton- 
wool. In all cases the temperature of the limb should be kept up 
during the process of separation and afterwards. 

The enfeebled condition of many of the sufferers from gangrene, 
and the exhaustion from the pain and sloughing, require the 
frequent administration of nourishment and stimulants, which are 
best given in a fluid form, especially when the tongue and mouth 
are dry. Opium is often given to soothe the pain and promote 
sleep, and if it is well borne, and does not disturb the stomach and 
head, greatly adds to the comfort of the patient. 

AMPUTATIONS. — A limb may be removed by the surgeon when 
it is useless to the jDatient, or where the presence of disease renders 
it necessary for the preservation of his health or life. The severity 
of the operation is increased the higher up in the limb the ampu- 
tation has to be performed ; thus amputation in the thigh is a 
far more severe operation than amputation of the foot. 

In addition to the usual necessaries of the operation-theatre, a 
small padded splint is requisite on which to bandage the stump, 
also broad pieces of strapping, for keeping the flaps together, should 
be cut beforehand, and the particular dressings required should be 
ascertained and prepared. 

When the patient is placed in bed the stump should be slightly 
raised on a pillow and left exposed for a time (see Haemorrhage). 
When covered, a cradle must be used to keep off the pressure of 
the bed-clothes. If there is sudden starting in the stump it must 
be confined on the pillow by a bandage passed round or across the 
bed. 

When dressing the stump the nurse should not take hold of it 
by the end, but should gently insinuate her fingers between the 
part above the pillow on which it rests, the back of the hand 
being towards the bed, and then sliding both hands down towards 
the end she should raise it from the pillow and support it steadily 
the whole time it is being dressed. 

RETENTION OF URINE.— Inability to pass water in the 



OPERATIONS AND SPECIAL SURGICAL CASES. 185 

female may be due to hysteria, or nervous conditions after opera- 
tions on the rectum or neighbouring parts. There is no obstruc- 
tion to the urethral passage, and the application of a hot 
fomentation to the pubic region in these cases is often sufficient. 
"When the bladder is much distended, forming a swelling at the 
lower part of the abdomen, or if there is obstruction to the passage 
of urine through the urethra, or for other reasons, it will be 
necessary to use the catheter. Every qualified nurse should be 
able to pass a catheter in the female. 

Passing Catheter for Female Patients. — The patient may lie 
on her back with the knees drawn slightly up. The nurse should 
stand on the right of the patient, and passing the left hand between 
the thighs place the forefinger between the labia at the orifice of 
the vagina. 

The catheter after being oiled should be introduced with the 
right hand and made to glide over the forefinger of the left until 
it slips into the orifice of the urethra, it should then be passed 
upwards and backwards till it enters the bladder. The fore- 
finger of the right hand should close the orifice of the catheter 
before it reaches the bladder, and the left hand disengaged carry 
the bowl to receive the urine. In withdrawing the instrument 
the orifice of the catheter should again be closed to prevent 
wetting the bed. 

The best instrument is a flexible elastic catheter (Xo. 8), such as 
is used for the male sex, but the silver female catheter may be 
used for ordinary cases. 

Retention of urine in the male is very common as the result of 
stricture of the urethra, enlarged prostate, and other causes, and 
the use of instruments of various kinds and sizes is employed by 
the surgeon. 

Management. — The nurse must know that serious consequences 
may result from retention if left too long, such as rupture of the 
urethra, and extravasation or escape of urine, or over distension of 
the bladder, and assistance should be summoned as soon as 
possible. She should also be acquainted with the various kinds 
of instruments, the silver, the gum elastic, the French " catheter 
a boule," and the soft india-rubber catheters, all of which are 
numbered according to their different sizes. She should have 
in readiness oil, vaseline, bowls, and hot water. 

Catheter Fever, or constitutional disturbance following the 
introduction of a catheter, occurs in some cases. The patient 
is seized with chilliness and a rigor, and his temperature rapidly 
rises. This may subside with a profuse sweat, or prolonged 
feverishness may ensue, A mild attack quickly yields to brandy 



186 A MANUAL OF NURSING. 

and water, or a dose of opium. When there is any sign of dis- 
turbance after the passage of a catheter, or in any case where 
a catheter is tied into the urethra and left, the nurse should 
watch the temperature, and report if there is any fever. 

Washing Catheters. — Inflammation of the bladder may be 
produced by the use of instruments that are dirty, and the nurse 
will be expected to see that they are clean. 

The catheter should be allowed to remain in a warm carbolic 
solution or warm water for a short time, and then held up with 
the rings, or numbered end downwards, and the contents allowed 
to run out. This should be repeated several times, and then 
by blowing through the eye it will bo ascertained to be clear. 
It should then be dried and the stilette introduced. 

STONE IN THE BLADDER produces a variety of symptoms, 
amongst which are — pain on passing water, a constant desire 
to pass water, with perhaps some changes in the urine, such as 
a sediment or blood. Children suffering from stone are apt to 
wet the bed at night, and pull themselves about, owing to pain in 
the penis. The urine should always be saved in case of suspected 
stone or bladder disorders. 

Lithotomy and Lithotrity. — The operation of cutting into the 
bladder for stone is called Lithotomy, and that of crushing the 
stone by an instrument passed into the bladder, Lithotrity. 

Management. — For lithotomy cases the bowel should be 
carefully emptied by an enema early in the morning of the 
operation, and the patient should be directed not to pass water 
for some hours before the operation, as it is convenient that the 
bladder should be partially distended. 

The bed should be arranged with a draw-sheet, and macintosh- 
sheet underneath, and will require much attention, as the water 
is constantly dribbling through the wound in the perinseum. The 
patient must be kept warm and dry, and the back should be 
bathed and dried. The nurse must be on the watch for haemor- 
rhage, especially in children, and she should keep herself informed 
whether the water is passed through the wound, or whether any 
is passed naturally, and if it contain blood or clots. 

Where there is troublesome haemorrhage after lithotomy the 
surgeon may find it necessary to plug the wound in the perinaeum. 
For this purpose an appliance may be used called a tube en chemise, 
which the nurse should know how to make. 

Tube en Chemise. — A gum elastic tube from six to eight inches 
long and half an inch in diameter is perforated at one end, and 



OPERATIONS AND SPECIAL SURGICAL CASES. 



187 




Fig. 54.— Tube en Chemise. 



fitted with two rings at the other. A piece of calico of ten to 
twelve inches square is then cut with a hole in the middle. The 
tube is passed through the hole, the calico folded round like a 
petticoat, and firmly 
secured by a piece 
of string wound 
round, about an inch 
from the perforated 
end (fig. 54). 

The surgeon then 
introduces the tube 
with the perforated 
end into the blad- 
der, and plugs the 
cavity between the 
calico and the tube 
with lint or cotton- 
wool ; the pressure 
thus exercised on 
the sides of the 
wound controls the bleeding. The tube can then be tied in by 
tapes passed through the rings, and attached to a T-bandage 
fastened round the waist (see ^-Bandage), 

After the operation of lithotrity everything passed from the 
bladder should be scrupulously saved, in order that any crushed 
remains of the calculus may be inspected. 

VESICOVAGINAL FISTULA— After difficult confinements, 
or other causes, a communication may be formed between the 
bladder and the vagina called a " fistula," through which urine is 
able to pass from the bladder into the vagina, and incontinence of 
urine is the result. To remedy this miserable condition an opera- 
tion is devised for uniting together the edges of the fistula. A 
successful result is difficult to obtain, and much depends on careful 
after-treatment and management. 

Management. — Before the operation the bowels must be 
thoroughly opened with castor oil and an enema. It is essential 
that after the operation no urine should find its way through the 
wound, and irritate the edges, and so prevent the fistula healing. 

To secure this a catheter is introduced into the bladder at the 
time of the operation, and tied in. This may be worn constantly 
until the wound has healed, being only removed occasionally for 
cleaning purposes. 

RECTAL CASES.— Fistula of the bowel is often caused by an 



188 A MANUAL OF NURSING. 

abscess forming near the rectum, and opening both externally close 
to the orifice and internally into the bowel. A tract is thus made 
and kept open by the faecal matter passing through. There is 
often a discharge of matter and blood, and pain may be intense 
when the bowels act. 

An operation is usually required to cure the fistula. 

Piles or Haemorrhoids are small tumours formed by dilated 
veins at the verge of the rectum. They may arise within the 
bowel, internal, or just without, external. 

They may be caused by constipation, congestion of the liver, 
pregnancy, or other causes, and they have often a tendency to 
bleed. When inflamed they give rise to great pain, especially 
when the bowels act. A bread poultice may give much relief 
when they are inflamed : a low diet, without stimulant, and an 
aperient or enema to unload the bowels are advisable. 

Kemoval of the piles with the ecraseur or clamp is often 
necessary. 

Management. — Previous to operation in cases of disease of the 
rectum of any kind, the nurse should make sure that the bowel is 
empty. An aperient over-night and a copious enema should be 
given early in the morning. The latter should be administered 
quite early, so that there is plenty of time for a thorough evacua- 
tion before the operation, as nothing is more annoying to the 
surgeon than to have the bowels acting at the time of the opera- 
tion. 

The nurse should prepare beforehand the dressings, and also the 
T-bandage, which is required in all operations on the rectum or 
perinaeum where dressings are used (see T-Bandage). 

It is comfortable for the patient after the operation that the 
bowels should not act for some days, and a light diet is advisable. 
There is sometimes difficulty in passing urine after these opera- 
tions, especially in females, and if not relieved by the application 
of a hot fomentation the catheter may be required. 

HERNIA. — A rupture is formed by a protrusion of some portion 
of the bowels through the wall of the abdomen. The pro- 
trusion occurs usually in one of three situations, — at the navel, 
in the groin, or at the upper part of the thigh, and the hernia is 
termed accordingly either an umbilical hernia, an inguinal 
hernia, or a femoral hernia. In all three instances the bowel 
finds its way through an opening or canal which naturally should 
be sufficiently closed to prevent it ; but it remains covered by the 
integuments and the soft parts, forming a soft, doughy swelling 
in the region of the canal which it has passed through. In the 



OPERATION'S AND SPECIAL SURGICAL CASES. 



189 




Fig. 55. — Truss for Inguinal Hernia, 
so as to create soreness or other discomfort 



majority of cases the hernia is what is called "reducible" and the 
bowel can be returned inside the abdominal cavity by pressure, or 
it returns of its own accord when the individual lies down. When 
he gets up, or makes any exertion, or coughs, it again protrudes. 

It is important that 
a person suffering from 
hernia should wear 
a " truss " to keep the 
bowel from coming 
down. The truss has 
to be adapted to the 
particular form of 
hernia, and it is es- 
sential that it should 
be efficient in keep- 
ing the bowel back 
without exercising 
any undue pressure, 
(fig. 55). # 

Umbilical Hernia is not uncommon in young babies. The 
protrusion is at the navel, and when the child cries it is often 
much increased in size, and causes pain. A firm pad can be 
easily adapted after the bowel has been pressed back through the 
canal, and then a broad flannel binder rolled twice or three times 
round the abdomen will keep it in position, and support the walls. 
The canal usually closes up as the child grows older, and the 
rupture ceases to come through if the pad is well and constantly 
arjplied. 

Inguinal Hernia is more common in men than women, and 
may protrude, forming a swelling at the groin, or the rupture may 
travel on down the canal into the scrotum, forming a swelling 
perhaps of considerable size. There may be a rupture on both 
sides. 

Femoral Hernia is more common in women than men, and 
gives rise to a swelling, often of small size, in the upper part of 
the thigh, at the inner side just below the groin. 

In any form of reducible hernia a truss should be fitted by the 
surgical instrument maker, and if there is any doubt as to its 
efficiency, the surgeon should be consulted. 

Strangulated Hernia. — Sometimes there is difficulty in return- 
ing the hernia, and the swelling becomes painful, the bowels do 
not act, and wind is not passed, and after a time other symptoms 
of obstruction set in, such as vomiting. This condition is due to 
obstruction of the passage of the bowel in the hernia, by the 






5 



190 A MANUAL OF NURSING. 

Constriction of the ring through which it has passed, and the 
bowel is said to be "strangulated" If this condition is not 
relieved fatal consequences will ensue* The surgeon should be 
immediately informed so that he may endeavour at once to reduce 
the hernia by a process called "taxis" or manipulation with the 
fingers. Failing this or the use of the warm bath, the patient will 
be placed under an anaesthetic, and if then the bowel cannot be 
returned, an operation has to be performed. 

Management. — In watching a case of strangulated hernia before 
operation, the nurse should only administer ice, or a very small 
quantity of fluid; she must be careful to save everything vomited, 
and not allow any aperient to be taken. The temperature and 
pulse should be taken, and the effect of opium, which is commonly 
administered in these cases, should be carefully noticed. 

After the operation a pad is applied by a spica bandage to the 
wound. The patient should not be allowed to move ; if sickness, 
coughing, or retching occur, the wound may be supported by gentle 
pressure with the hand, to prevent strain. The diet allowed is 
only small quantities of milk, or fluid of some kind. No aperient 
should be given, but opium is frequently prescribed. Any com- 
plaint of pain in the abdomen should be attended to, and the 
temperature carefully noted. 

Eecovery is usual after operation for strangulated hernia, unless 
the strangulation has been allowed to remain unrelieved too long, 
and the bowel has suffered damage. 

A suitable truss should be worn afterwards. 

OVARIOTOMY. — In ovariotomy and other abdominal opera- 
tions each surgeon has his own particular plans for nursing, and 
usually prefers to employ nurses specially trained under him, that 
they may be acquainted with his methods, and pay attention to 
those details in the after-treatment, which he considers of the 
greatest importance. It is only necessary therefore to mention the 
more general points in the management and after-treatment of 
ovariotomy, those in fact which a nurse who has received an 
ordinary training would be expected to know, should she be called 
upon to take charge of a case of this kind. At the same time, for 
the successful management of all abdominal cases, the extreme 
importance of practical acquaintance with small details cannot be 
too strongly insisted on. 

Before Operation. — In addition to the ordinary rules to be 
observed; vtheocathetea? miay^be- passed -for *,a- few~ days previously, 
and tfe& bladder: ihiust aMEys .bei'&mp^Ted/>jds^^ 
Tfcei bowe^SijdwDtal&l&cfcifi^^ anQ dn m&m±foib 



OPERATIONS AND SPECIAL SURGICAL CASES. 191 

given about four hours before the operation. In patients suffering 
from debility, two or three ounces of brandy may be injected by 
the rectum shortly before the anaesthetic is given. 

The cleanliness of the body must be secured by a bath, and the 
abdomen should be well sponged over with carbolic solution. 

The patient must be warmly clad, and should wear a flannel 
dressing-gown and warm stockings. 

The room in which the operation is to be performed must be 
previously scrubbed and cleaned, and kept at a temperature of 
about 70° Fahrenheit. 

The ordinary requisites for the operation-room must be prepared, 
and in addition two or three empty buckets, sponges, and sponge 
holders, flannel bandage, antiseptic dressings, and a special mack- 
intosh-sheet. 

The buckets are required to hold the fluid which is contained 
inside the ovarian tumour or cyst, often in considerable quantities. 

The sponges must be of medium size, soft, absolutely clean or 
new, and well wrung out in warm antiseptic solution. There 
should be a dozen or more, and the number in use at the time of 
the operation should be counted and noted down, in order that it 
may be ascertained before the wound is closed that all the sponges 
have been removed from the interior of the abdomen. 

The flannel bandage must be of sufficient width to reach from 
the lower end of the breast-bone to the pubes, and the " many- 
tailed bandage " is the form in common use (see Many-tailed 
Bandage). The mackintosh-sheet is previously prepared by cutting 
out a portion in the centre to form an oval aperture, the length of 
the proposed incision in the abdomen. The sheet round the 
aperture is covered with a broad band of adhesive plaster to fix it 
down to the abdomen. 

After Operation. — The room in which the patient is placed 
after the operation should be kept at about 65° to 70° Fahrenheit. 

The bed may be made with a new or fresh mattress, and should 
be arranged with a mackintosh under the draw-sheet. The upper 
bed-clothes may be folded so as to open in the middle and facilitate 
passing the catheter, or dressing the abdomen ; and a pillow may 
be placed as a support underneath the knees. Warm bottles 
should be placed in the bed before the patient leaves the operation- 
table. The patient must lie on her back, no movement being 
allowed, and the urine should be drawn off with the catheter 
every four or six hours. 

Complications after Ovariotomy. — Secondary haemorrhage 
may occur from the giving way of a vessel internally, and might 
arise soon or several hours after the operation. The main indica- 



192 A MANUAL OF NURSING. 

tions would be faintness, blanching of the face, sighing, with 
perhaps pain in the abdomen and low temperature. 

Peritonitis is the usual cause of death in the unsuccessful cases, 
and may supervene at almost any time during the earlier periods. 
A careful watch should always be kept on the pulse and tempera- 
ture, and if there be access of abdominal pain, with vomiting, 
shivering, associated with fever, the onset of peritonitis should be 
suspected (see Peritonitis). 

The nurse will receive definite instructions from the surgeon 
as to the management and diet of each particular case, also 
whether opium or aperients have to be given. 

During convalescence, the abdomen will require some support, 
either a broad flannel binder, or a well-fitting flannel belt, 
strengthened, and furnished with buckles. 



CHAPTER XIII. 

The Management of Child-Bed. 

Before Labour— Lying-in Room — Preparation of the Bed— Precau- 
tions against Infectious Diseases — Indications of Commencing 
Labour— Pains— Stages of Labour — Management of Natural 
Labour — Antiseptic Rules for Monthly Nurses — Management 
after Labour — Lochia — Lactation — Prevention of Puerperal 
Fever — Antiseptic Solutions. 

Management of the Infant — Separation— Washing and Dressing- 
Rashes— Navel — Eyes— Rupture— Snuffles. 

Preliminary Arrangements, 

There are certain preliminaries before the onset of labour con- 
cerning which the nurse has usually an opportunity of informing 
her charge, and this is especially desirable in first labours or 
primiparous women towards the termination of pregnancy. 

If the health be tolerably good, moderate exercise should be 
recommended, and invalid habits discouraged. It is often possible 
during the last weeks of pregnancy for walking exercise to be 
taken easily, when previously accompanied by much discomfort. 
The diet should be generous and sufficient, but not stimulating. 
The state of the bowels should be carefully regulated by laxatives 
if necessary, and at the approach of labour the large bowel should 
be emptied by the administration of an enema. A tedious labour 
may be the result of neglect in this particular. 

The Lying-in Room. — The temperature should average from 60° 
to 65° F., and the room should be well ventilated. In warm weather 
the windows may be opened, and the patient protected from draughts 
by a screen. In winter a fire should be kept burning in the grate, 
and the windows opened according to the state of the weather. 
The room should not contain an unnecessary amount of furniture, 
and curtain hangings about the bed are imdesirable. Absolute 
cleanliness in every respect is imperative. 

The wash-hand stand must be prepared when labour commences, 
and should contain three basins, one for washing with soap and 
water, and the other two for antiseptic solutions. One of these 

N 



194 A MANUAL OF NURSING. 

may be used for the hands and the other kept for cleaning the 
different instruments. 

Preparation of the Bed. — After the bed has been made in the 
ordinary way, a mackintosh is placed upon the lower sheet, of 
sufficient width to tuck in on either side, and deep enough to 
extend from the small of the patient's back to the knees ; over 
this a draw-sheet should be doubled and placed crossways to the 
bed, so as to overlap the mackintosh a few inches in each direction. 
The bed can thus be kept constantly dry, and the draw-sheet 
changed by rolling up, and moving the patient while another is 
substituted (see Draiv- Sheet). 

Special Precautions. 

Infectious Diseases. — The lying-in patient is very susceptible 
to diseases of an infectious nature, and the nurse should be 
careful to avoid contact with any one suffering from fever of any 
kind, or the neighbourhood of any infectious malady. Such 
diseases as erysipelas, small-pox, scarlatina, and especially puerperal 
or child-bed fever, are dangerous. A nurse who is aware that she 
has been exposed to infectious illnesses should, before undertaking 
a monthly case, inform the medical attendant, and ascertain if she 
is justified in doing so after the adoption of the proper precautions 
for disinfection (see Disinfection). 

Management of Natural Labour. 

The indications of commencing labour are the presence of uterine 
pains, and a discharge of mucus tinged with blood. 

The pains felt at an early period of labour are situated over the 
front of the lower part of the abdomen, and are tolerably regular, 
cutting in character, reaching a certain pitch of intensity, and 
gradually subsiding; there may be intervals during which the 
pains are absent for several hours. 

False pains are due to flatulence, or some bowel disturbance, and 
do not accelerate labour ; they are short and irregular in character. 

The stages of labour are three, during which certain events 
take place : — 

In the first stage the orifice of the womb is dilated to permit of 
the passage of the child, and the membranes covering the child are 
ruptured. The pains which occur during the first stage are such 
as have been described above, and are caused by the dilatation of 
the neck of the womb by the bag of membranes. Several hours, 
to a day or more, are occupied by the process, and it is often 
accompanied by a sense of nausea, vomiting, or attacks of shivering. 



THE MANAGEMENT OF CHILD-BED. 195 

When, at the end of this stage, the membranes have ruptured 
and the waters have escaped, the next stage follows. 

In the second stage of labour, the pains increase in intensity, and 
are felt in the sacrum or lower part of the back; they gradually 
become more violent and expulsive in character until the child is 
born. Towards the termination of the first stage and the com- 
mencement of the second, the patient feels constant desire to pass 
water. 

The third stage is occupied by the expulsion of the placenta or 
after-birth, and there is usually an interval of fifteen to thirty 
minutes after the second stage before the pains succeed which 
expel the after-birth. 

Management. — In first labours the early stages are apt to be of 
long duration, and considerably exceed those of women who have 
borne children. False hopes should never be held out that the 
labour will be a quick one, or that it will soon be all over, as the 
patient rapidly loses confidence when she finds that she is dis- 
appointed. 

When the first stage is protracted, the patient should be advised 
to occupy herself and keep about as far as possible during the 
day-time, and sleep when she feels inclined. The feeding should 
not be neglected, and milk, beef-tea, soups, or other nourishment 
may be given regularly ; exhaustion renders the pains less effective, 
and often prolongs the final stages. Stimulants are unnecessary 
when food is well taken. An enema may often prove of advant- 
age in slow cases during the first stage. 

During the second stage the patient should lie on the bed, and 
may aid the expulsive pains by holding her breath, and bearing 
down or straining, unless they are too violent. Great relief is 
often given by the nurse supporting the lower part of the back by 
firm pressure with the hand. As soon as the child is born, the 
cord should be noticed in case it be twisted tightly round the 
child's neck, and if so, it should be gently drawn down, and 
slipped over the head (see Child, Separation of). 

The mother should remain perfectly quiet after the birth of the 
child. A short time elapses before the after-birth is expelled by 
a few sharp pains, a process which may be assisted by the patient 
coughing a few times.- Traction or pulling on the cord should not 
be practised, being not without danger. It is at this period that 
flooding is apt to occur, and the nurse should be on the watch for 
excessive haemorrhage. After the third stage of labour the binder 
may be applied (see Binder). 

Vaginal Examinations. — To place a patient in the so-called 
obstetric position for an examination, the clothes around the waist 



196 A MANUAL OF NURSING. 

should be unloosened, so that the abdomen can also be examined, 
and the diaper or pad removed. The patient must be turned well 
on to the left side, with the head low on a pillow placed at the left side 
of the bed, and the trunk lying right across the bed. The buttocks 
should overlap the edge on the right hand side, the legs should be 
drawn up so that the thighs form a sharp angle with the trunk, 
and the knees should be as close as possible to the chin. It is a 
good plan to turn the upper sheet over the counterpane on the 
right hand side of the bed, and secure it there with nursing pins. 
A napkin folded diagonally should always be at hand to guard the 
doctor's arm during the examination. 

Antiseptic Eules for Monthly Nurses. — Every nurse should 
practise systematically the following rules unless otherwise directed, 
or modified by the medical attendant : — 

1. The hands must be kept clean, and the nails cut short, the 
nail-brush being constantly in use with soap and water. 

2. During and after labour, a small basin containing an anti- 
septic solution must always stand by the bedside of the patient, 
and the nurse must thoroughly rinse her hands in it every time 
she touches the patient in the neighbourhood of the genital organs 
for any purpose whatever, either of douching, washing, &c. 

3. Vaginal pipes, enema tubes, catheters, sponges, &c, should be 
kept permanently in the antiseptic solution, except when in use, 
and cleaned in a similar solution before and after using. 

The surfaces of slippers and bed-pans should also be sponged 
with it. 

4. Vaginal pipes, tubes, &c, should be smeared with carbolised 
vaseline before use. 

5. Unless express directions are given to the contrary, the vagina 
should be douched night and morning- with antiseptic solution. 
The hot douche, if ordered, should be given at a temperature of 
115°. Care must be taken to have the pipe and tube filled with 
the solution, and devoid of air-bubbles before insertion, and 
sufficient should be allowed to pass through to warm the apparatus. 
During the administration of the douche, pressure may be main- 
tained on the womb by the hand placed on the abdomen. 

6. All soiled linen, diapers, &c, should be immediately removed 
from the bed-room ; soiled pads should be burnt. All bed-pans, 
urine-boats, and bed-baths should also be removed as soon as 
possible, and after they have been emptied, they should be washed 
and disinfected. 

7. The nurse is recommended to wear a light-coloured dress 
of washing material, with apron and sleeves, which easily 



THE MANAGEMENT OF CHILD-BED. 197 

show the dirt, and the skirts should be sufficiently short to escape 
sweeping the floor. 

Application of the Binder. — This should consist of huckaback 
towelling, thirty-six inches wide, and one and a quarter yard long, 
doubled lengthways. Its lower edge should reach four inches 
below the top of the thigh-bone. The free end of the binder 
should be uppermost on the right side. Starting from the left flank, 
the binder should pass over the abdomen, ending on the right 
flank, where, after it has been tightened, and all creases smoothed 
out, it should be securely fastened by four strong pins. The 
patient's skin should be guarded by the left hand beneath, whilst 
the pins are inserted. Straight pins, two inches long, are the best. 

Management after Labour. 

For the first three days after labour the horizontal position must 
be maintained, and exertion and sudden movements should be 
avoided. After this the head may be raised by a pillow, and the 
patient propped up to take food, but she should not be allowed to 
sit upright in bed. On the eighth or tenth day, if doing well, 
most patients may be allowed to be outside the bed-clothes in a 
dressing-gown, and in a day or two more they may sit in a chair, 
or lie on the sofa for an hour at a time. The progress varies 
greatly in different cases, some requiring much longer rest than 
others. In delicate persons, or where there is much anaemia, or 
debility after flooding, the horizontal position has to be enforced 
for a much longer period, and the erect position should not be 
assumed quickly or suddenly. 

If the lochia become red or free, or there be marked rise of 
temperature when the patient begins to get up or to move about, 
she should be kept quiet on the sofa. 

Temperature. — After delivery the temperature should be taken 
at regular times twice a day, or more often if desired. If there is a 
sense of chilliness, the temperature should be ascertained, and if a 
rigor occurs, the temperature should be taken every half-hour, and 
a hot bottle applied to the feet, while warm milk or beef-tea should 
be given. 

Constant feverishness, rigor, or sudden high temperature should 
always be reported as early as possible. 

Lochia. — Three points should be noted — the amount, the 
colour, and whether offensive or not. If any clots or shreds are 
passed, they must be removed and kept for inspection. At first, 
the lochia should be of pure blood and fairly free, being increased 
by relief of the bladder or bowels, and during the presence of after- 
pains. In a few days the quantity of the flow diminishes, and 



198 A MANUAL OF NURSING. 

the colour becomes lighter and less tinged, and then turns to a 
greenish colour before ceasing in two or three weeks time. 

Suppression of the lochia at an early period, associated with 
other signs, or an offensive odour, and decomposing clots or shreds, 
are bad symptoms, and should be immediately reported. 

Bowels. — It is a good plan to administer a dose of aperient 
medicine on the morning of the third day, and an enema may be 
given the same evening. 

Bladder. — Unless otherwise ordered, the urine should be 
passed in the knee-and-elbow position, with the assistance of 
the nurse, and the bladder should be emptied two or three times 
in the twenty-four hours without straining. If there is any diffi- 
culty, this may be remedied by the application of a warm fomen- 
tation to the vulva, or, if necessary, by the use of the catheter. 
The latter should be preceded and followed by antiseptic ablutions. 
The urine may be required for examination a few days after 
delivery, and in that case will have to be drawn off with the 
catheter. 

After-Pains. — These are most common in women who have had 
several children, and may continue for three or four days, pre- 
venting sleep if severe. There may be no cause apparent, or else 
they may be attended by the passage of clots. The douche may 
remove these and the pains subside, or they may require some 
opiate medicine. 

Lactation. — There is not, usually, sufficient milk secreted by 
the breasts for the infant before the third or fourth day, and this 
incident may be attended with some feverishness and slight con- 
stitutional disturbance, called milk fever. 

The child should be put to the breast for a few minutes only, 
three times in the first twenty-four hours, until the milk is 
established, and after that for ten minutes regularly every two or 
three hours unless it be asleep, to one breast only at each meal. 
The breasts should be used alternately. 

If the nipple does not stand out well, or the child has difficulty 
in suckling, it should be drawn out with a shield, this being 
carefully cleansed. The nipples before the first confinement 
should be hardened with spirit, or eau-de-Cologne, and, if necessary, 
drawn out. After the child is taken from the breast, the nipples 
must be washed and carefully dried with a soft napkin. If the 
nipples are carefully attended to, they rarely become sore, but if 
this happens they may be moistened with glycerine of borax. 
If the breasts become hard and painful from the flow of milk they 
may be rubbed with the hand lubricated with oil in a direction 
from the circumference to the nipple. If the breasts hang down 



THE MANAGEMENT OF CHILD-BED. 199 

and feel heavy, relief may be obtained by the support of a folded 
napkin passing under each and round the opposite shoulder. 

If it is necessary to apply glycerine of belladonna to the breasts 
to dry up the milk, it is very important to avoid the nipple. 
The application should be smeared on lint and covered with 
protective ; the latter should overlap the lint an inch in every 
direction, and a hole should be cut in both for the nipple, the 
hole in the lint being considerably larger than the one in the 
protective. The whole should be then covered with a pad of 
cotton-wool and kept in place by a napkin. The wool may be 
replaced when it has been saturated by the milk. TVliile the 
milk is being dried up, the supply of liquid food to the patient- 
should be diminished. On no account must the child be put to 
the breast after the belladonna has been applied, but if the 
secretion is too copious, the excess of milk may lie drawn off with 
the breast pump. The flow will commonly subside without the 
application of the belladonna, if the breast is rubbed well with 
the hand lubricated with camphorated oil. 

The mother should not be allowed to sleep while the child is 
taking the breast. 

Xipple-shields may be employed if the nipple is too sore to 
allow the child to suck directly. 

Lacerations of Perinseum. — Tearing of some or other part of 
the external genitals occurs most commonly in first labours. The 
patient should be kept on her side with the knees bound together, 
and it is important that the lacerated surface should be wetted as 
little as possible. It may be kept dry and clean by the absorbent 
cotton-wool. In cases of lacerated perinaeum the catheter may be 
used, or else the patient should be directed to pass water in the 
hand and knee position before using the bed-pan, or before the 
douche is given. Straining should also be avoided. 

INFLAMMATORY DISORDERS AND PUERPERAL 
FEVER. — Inflammation connected with some part of the womb 
or its appendages may supervene after delivery, accompanied with 
feverishness and local pain in the abdomen. 

Inflammation of any kind is a symptom of importance after 
delivery, and should be immediately reported. A hot fomentation 
may be applied to the abdomen, which commonly gives relief (see 
Peritonitis). 

Puerperal fever is the most dreaded after-complication of child- 
bed, and is often marked at its onset by one or more severe rigors 
with speedy elevation of temperature ; the face becomes flushed, 
and there are other constitutional symptoms of greater or less 



200 A MANUAL OF tfURSING. 

severity. The special symptoms connected with it are — suppression 
or offensiveness of the lochia, failure of the milk supply, abdominal 
pain and distension, with tenderness over the uterus. In fatal or 
severe cases the course taken by the fever is similar to cases of 
septicaemia or blood-poisoning. 

Prevention. — The prevention of this very fatal disease is in 
great measure in the hands of the nurse. By the most careful 
and absolute cleanliness on her own part, by close attention to the 
hygienic condition of the lying-in chamber, and to the details of 
antiseptic midwifery, the number of cases will be reduced to a 
minimum, and the nurse will feel that she has exercised every 
precaution in her power. If such a case should occur under her 
charge, she should make every effort to ascertain whether it might 
be due to any preventible cause. 

The condition of the lavatory, or closet, any defect in the 
drainage, or unsanitary surroundings which may have been 
previously overlooked, should be searched for, and the presence 
in the house of any one carrying infection from the outside should 
also be the subject of inquiry. 

Antiseptic Solutions. 

Antiseptic Solutions for use in the lying-in room are : — 

Perchloride of Mercury — Corrosive Sublimate. — A standard 
solution should be kept ready of the strength of 1 in 200, and 
diluted for use to 1 in 2000 by adding 9 parts of water to 1 
part of the standard solution. The antiseptic properties of the 
solution are destroyed by soap; in consequence of this it is 
necessary to thoroughly rinse the hands of soap before they are 
soaked in the antiseptic solution. 

Carbolic Acid. — A standard concentrated solution of 1 in 20 
should be kept ready, and corresponds in strength to a 1 in 1000 
solution of perchloride of mercury. 

Condy's Fluid — Permanganate of Potash. — This should be 
employed in solution of the strength of one teaspoonful to a pint 
of water. It is useful in indicating the presence of septic matter 
in the part to which it is applied, by a change of colour from 
purple to brown, and its use must be continued until the colour 
remains unchanged. 

Condy's Fluid should not be used with soap, carbolic acid, oil, or 
glycerine, all of which decompose it. 

MANAGEMENT OF THE NEW-BORN INFANT. 

Separating the Child. — Immediately the child is born, the 
eyes, nose, mouth, and throat should be carefully wiped with a 



THE MANAGEMENT OF CHILD-BED. 201 

clean napkin. The ligatures and scissors should be placed ready 
before delivery. The ligatures consists of five or six strands of 
sewing thread, eight inches long, knotted together at either end 
and rendered antiseptic ; the scissors should have rounded ends. 
AVhen pulsation has ceased in the cord it should be tied in two 
places, one at least two and a half inches from the navel, and the 
other an inch further off. The first knot should be firmly and 
tightly pulled until the resistance of the cord is felt to give way, 
before being secured with a reef-knot. When both ligatures have 
been applied, the intervening cord may be divided midway with 
the scissors. The navel should not be dragged upon when the knots 
are being tied or the cord divided. The end of the cord attached 
to the child should be examined after it has been wiped dry to 
ascertain that there is no oozing of blood, and that the ligature is 
secure, otherwise it will be necessary to make it so by a second 
ligature. The baby may be placed in a flannel receiver, and 
removed. 

Washing and Dressing the Baby. — After labour, the nurse 
must not leave the mother to attend to the baby until everything 
has been done for her that is required ; the baby in the meantime 
being placed in a warm and safe position. Everything should be 
prepared ready beforehand for washing and dressing the infant. 

Infants must be bathed at a temperature of 96°, quickly dried, 
powdered, and dressed in front of a fire, and not unnecessarily 
exposed to the cold air. The eyes, mouth, nose, and ears must be 
first attended to; they require great care in washing, and all 
creases and folds of the skin should receive special attention, and 
be thoroughly dried and well powdered. 

In the first washing the cheesy material often found coating the 
child may be removed by the application of oil or vaseline. The 
child should be well lathered all over witn soap and soft flannel, 
and then dipped in the bath, and the soap well rinsed off. "When 
the child is in the bath, the nurse can, by placing the left hand 
under its back, and at the same time supporting its neck with the 
fore-arm, gain a sufficiently firm hold on the child, the head being 
prevented from falling back into the water, while her right hand 
is left at liberty. 

Before dressing the child, care must be taken to see that the 
cord has been efficiently tied, and that no oozing is taking place 
from the stump. Having been carefully dried, the navel-string 
must be wrapped up in antiseptic gauze or lint. A hole is cut for 
the cord in the centre of a piece of this material about six inches 
square, and after freely dusting the cord the four sides are folded 
round it. The cord and its dressings ought to be kept firmly in 



202 A MANUAL OF NURSING. 

place by a flannel roller, five inches wide and twenty-four inches 
long. This must be firmly applied, and the end over-sewn. If 
the child is bathed every day, the dressings will have to be 
renewed, but if washed without immersing in the bath care must 
be taken to avoid wetting the dressing. The further dressing of 
the child varies. In the hospital, the child is first turned over on 
its belly, the shirt put on, a napkin folded diagonally being laid 
over the back, and a flannel petticoat placed on it. The child 
is then turned over, the napkin folded, and the shirt and flannel 
petticoat brought round the chest and also folded. These are 
fastened in position by a white binder four inches wide and three- 
quarters of a yard long, rolled round like the flannel, and 
also over-sewn. In dressing a child no pins should be used. The 
pilch is put on like the napkin, but the lower corner, instead of 
being brought up between the thighs, should be left loose. The 
long flannel petticoat also folded over the feet, either towards the 
front or back, and fastened with two or three stitches, keeps the 
pilch in place. The child's night-dress can then be slipped up 
from below over the legs, the arms placed in the sleeves, and the 
garment fastened behind. The head flannel thrown loosely over 
the head and shoulders completes the dressing. 

In many private houses the swath has fallen into disuse, and 
all the garments may be made to fasten behind, so that they can 
be stitched together, and all put on at the same time. 

Points to be Noted, 

Rashes. — Infants are frequently affected with rashes, a common 
one consisting of red elevated pimples, being called the "red- 
gum " (strophylus). It may be produced by gastric disturbance, 
or by the child being too closely covered up. The head flannel 
must never be worn in bed. 

Micturition. — Inability to pass water may often be relieved by 
placing the child in a warm bath. If unrelieved, or there is pain, 
the fact should be reported. 

The Navel. — The cord usually separates on the fifth or sixth 
day. It should always be kept clean, dry, and powdered. The 
odour should be noticed, whether offensive or not. After separa- 
tion, the surface should be examined, whether bleeding, discharg- 
ing, inflamed, or otherwise unhealthy. 

Starting of the navel or unusual prominence on crying should 
be reported, as it may be necessary to apply a compress. 

Breasts. — The breasts in children of both sexes are apt to swell 
in the first few days after birth, and even to secrete milk. No 



THE MANAGEMENT OF CHILD-BED. 203 

treatment is generally required. They should be protected from 
being rubbed or irritated by a pad of cotton-wool. 

Eyes. — Attention to the eyes is a point of the very greatest 
importance, and in which neglect may be followed by impairment 
or complete loss of eyesight. Any weakness of the eyes should be 
noticed and at once reported. The application of a little sweet- 
oil or vaseline to the margin of the lids, after they have been 
bathed with warm water, prevents them from sticking together, 
and causing further damage by the action of pent-up matter. If 
there is discharge it should be constantly removed, and the eyes 
bathed. The matter is infectious, and care should be taken not 
to infect the sound eye by using sponges or lint which have been 
applied to remove the matter from the inflamed eye. All should 
therefore be burnt, and the nurse's hands carefully disinfected. 

Swelling in the Groin. — A swelling in the groin may be due 
to various causes, especially in males. A soft swelling which 
increases in size when the child cries, but decreases or disappears 
at other times, is in all probability a hernia. All such cases should 
be reported. 

Snuffles. — Apparent cold in the nose, when persisting, is a 
strong indication of syphilis. It may often be relieved by apply- 
ing vaseline to the bridge of the nose. 

Buttocks. — The buttocks must be kept as clean and dry as 
possible, especially if the motions are green and liable to irritate ; 
consequently, in cases of diarrhoea and thrush, scrupulous atten- 
tion is required. Xapkins washed in soda and insufficiently 
rinsed are irritating, and apt to produce soreness of the buttocks; 
the same remarks apply to napkins which, having been soiled, are 
dried, and again put on the child unwashed — such a practice is 
objectionable and cannot be too strongly condemned. A little 
vaseline or zinc ointment rubbed on the buttocks after they have 
been washed protects the skin to a certain extent from irritating 
discharges. 

If the buttocks become sore, the fact must be mentioned. Spots 
limited to the buttocks which break at the summit and leave 
minute holes are probably of a syphilitic nature, and this is 
rendered still more probable if the soreness has appeared in the 
absence of green stools. All sore spots on the buttocks may be 
touched with an iodoform pencil each time the napkin is changed, 
as if these minute ulcers increase in size, and run together, they 
produce a very raw surface. 

A syphilitic child generally snuffles and has a hoarse cry ; is 
frequently small, ill-nourished, and weakly, with an aged look 
and wizen-face, and is liable to various eruptions. 



CHAPTEK XIV. 

Appliances. 

Baths : — Vapour-Bath — "Wet Pack— Half Pack — Tepid Sponging — 
Enemata, Aperient and Nutrient — Douche — Vaginal Injec- 
tions — Nasal Douche — Ice Bags — Poultices — Mustard Leaves — 
Fomentations and Stupes — Counter-Irritation — Blisters — 
Leeches — Cupping, Wet and Dry — Ointments— Suppositories — 
Eye-Drops — Collyria — Ear Syringing — Throat Applications — 
Gargles— Sprays — Inhalations— Bronchitis Kettle 

Various Kinds of Baths. 

BATHS (Hot and Warm). — In preparing a warm bath for an 
invalid, the necessary temperature should be previously ascertained 
from the medical attendant. In ordinary cases a hot bath should 
be from 100° to 108° or 110° F., the patient remaining in from ten 
to fifteen minutes. The temperature of a warm bath ranges from 
90° to 100°, and of a tepid bath from 80° to 90°, in all cases 
regulated by a thermometer. 

The nurse should prepare the bath of a low temperature, adding 
hot water to prevent the water cooling or to increase the tempera- 
ture. The patient may be immersed from half to one hour. 

In cold weather the bath should be given before a good fire and 
a warm blanket kept ready for the patient afterwards. 

The patient's body should be wholly immersed except in cases 
of respiratory difficulty, when the chest should be left out of water 
covered with a blanket. 

Invalids are liable to fainting attacks when taking a hot bath, 
so that the attendant should not leave them alone for fear of their 
passing into an unconscious state. 

Exposure to draught should be avoided when drying, and the 
patient should go to bed without delay. 

In giving a child a bath for fits, the child should be seated in the 
hot bath, and a sponge full of cold water squeezed over the head. 

Continuous Bath. — In the case of a patient suffering from 
extensive burns, it may be desirable to keep him constantly in the 
bath. The bath should be kept at a temperature which he feels 



APPLIANCES. 205 

comfortable, and he may be slung in it with a support for the 
head, the nurse remaining by his side. 

In preparing hot baths for the irresponsible and children, 
accidents may be saved by putting some cold water into the bath 
before the hot tap is turned on, so that if the child should enter 
before the bath is ready there is no chance of its being scalded. 

Cold Bath. — For those in fair health this is best taken 
before breakfast, and should be followed by a sensation of glow 
and warmth. The body need only be immersed or sponged for a 
minute or two, and then rapidly dried. If the cold bath is ordered 
for those in delicate health, it may be taken two or three hours 
after breakfast. Children may be allowed to stand in hot water, 
and be then rapidly sponged over with cold water. 

Graduated Cold Bath for hyperpyrexia. TVlien the bodily 
heat exceeds 105°, and is attended with the first symptoms of coma 
and an increasing rise of temperature, the cold bath may be 
necessary. It is given under medical superintendence, not being 
free from risk. 

A bath of sufficient size to immerse the patient is required, and 
one which can be wheeled to the bed-side is most convenient. 
The patient after being stripped should have a large towel spread 
over him, and then be lowered by means of a sheet or blanket 
into the bath, which should be of a temperature of about 90° F. 
The water is then cooled down by adding cold water, or if necessary 
ice, until the temperature gradually reaches 70° or 65°, or until 
the patient's temperature, ascertained by a thermometer placed in 
the mouth or rectum, is sufficiently lowered. The patient can be 
removed by several strong hands, or else be lifted out by means of 
the blanket or sheet in which he was lowered, the water being 
drained off as far as possible. 

The bath may have to be repeated several times, if the tempera- 
ture again ascends ; and if followed by shivering, or great lividity, 
the patient should be placed between the blankets, and hot-water 
bottles applied to the extremities, warm beef-tea or brandy being 
administered by the rectum. 

In cases of emergency where a cold bath cannot be given in this 
form, the patient may be placed in a large mackintosh, and the 
bed tilted upwards at the head, a bath being placed at the foot of 
the bed, and the mackintosh held up at the sides. Cold or iced 
water is then directed over the patient from above, and the water 
guided into the bath at the foot of the bed. Other substitutes 
may be used, such as cold sponging, or the cold wet pack. 

Hip-Baths. — These are useful in disease of the pelvic organs, 
when it is not desirable to immerse the whole body. Care should 



206 



A MANUAL OF NURSING. 



be taken not to fill them too full so that the water runs over when 

the patient sits down, and the upper part of the patient should be 

covered with a blanket. 

Foot-Bath. — A mustard bath may be employed for the feet. The 

foot-bath should contain 
water at about 110° F., 
to which an ounce of 
mustard has been added : 
the feet may be kept in 
it until a warm glow is 
felt in the skin. 

Hot-Air Bath. — To 
promote perspiration in 
dropsy, Bright's disease, 
or chronic rheumatism, 
these baths are invalu- 
able. They are best 
given to the patient in 
bed by making use of 
Allen's lamp, the boiler 
being removed. The 
patient is stripped, 
covered in flannel or a 
blanket, and a blanket 
is laid on the bed ; a 
body-cradle or wicker- 
work support is then 
placed on the bed over 
the patient and one or 
more blankets thrown 
over this, so as to com- 
pletely cover him, and 
the clothes tucked in 
round the bed close to 
the neck. The covering 
blanket being removed, 
the lamp is then lighted, 
and raised from the 
ground to the required 

height, the tube being passed under the bed-clothes above the level 

of the body (fig. 56). 

The hot air enters and surrounds the body in a warm bath, soon 

producing a copious perspiration. The head may be wrapped 

round in a towel wrung out in cold water, and changed if neces- 




APPLIANCES. 207 

sary. Fifteen to thirty minutes is usually a sufficient length of 
time for the bath, and the patient must not be left alone. The 
effect may be much increased by imbibing plenty of fluids, or by 
the previous administration of drugs, such as pilocarpine, which 
encourage perspiration. 

The temperature of the bath should be measured by a thermo- 
meter suspended inside the cradle, and may range from 110° to 
150° F. 

Vapour-Baths may be given in the same way if steam is used 
instead of air, the temperature varying from 100° to 110° F. Ex- 
tempore arrangements may be made with a kettle provided with a 
long tube to pass under the bed-clothes and convey the steam, or 
bricks may be heated and wrapped in a flannel which has been 
previously soaked in water, or vinegar and water, and then placed 
on a dish inside the bed under the raised bed-clothes. Some form 
of cradle may always be extemporised with card-board or some 
stiff material, such as half a band-box, &c. 

The same baths can be given to an individual in a sitting 
posture. The patient being seated in a cane-bottomed chair, the 
lamp is placed underneath the chair, and then a blanket is arranged 
to cover and surround him and the chair, but leaving the head 
uncovered (fig. 56). 

Mercurial Vapour-Bath. — The patient is enveloped in a 
blanket, and seated in a chair as above described, but in addition 
to the steam produced by boiling water, a small dish of calomel is 
placed over a spirit-lamp under the seat of the chair. The vapour 
of the calomel is carried with the steam around the naked body of 
the patient. The amount of calomel to be used will be prescribed 
in each case, and the patient should remain for about twenty 
minutes, when the calomel will have disappeared. 

WET PACK— The Cold Wet Pack is used to reduce tempera- 
ture in fever, or to promote free perspiration and sleep. The bed 
should be guarded by a waterproof sheeting, with a blanket placed 
over it ; the patient is then stripped, and lies on his side with a 
blanket over him. A sheet, previously wrung out in cold water, 
is folded lengthways with the edges towards the middle, and is 
closely adapted all over the patient under the blanket, but leaving 
the head uncovered ; the blanket is then tucked round him. 

The Hot Wet Pack is given in a similar manner, hot water at 
110° F. being used instead of cold, and three or more blankets are 
thrown over the patient and tucked round, two hot bottles being 
placed at the feet and one on either side. The effect of the pack 
must be noticed, and if severe exhaustion is produced it must not be 



208 A MANUAL OF NURSING. 

continued ; but if the result is a feeling of comfort it may be con- 
tinued for half an hour or more, when the patient may be quickly 
sponged with tepid water, dried, and wrapped in a blanket. 

The Half Pack is a modification of the cold wet pack, and is 
carried out in much the same manner. Instead of the large sheet, 
one or two towels folded lengthwise should be wrung out in cold 
water, and folded round the body below the armpits and over the 
hips, leaving the limbs uncovered; the blanket is then folded 
round and tucked in. 

Tepid Sponging may be employed with great benefit and com- 
fort to the patient in cases of fever and restlessness, and reduces 
the temperature when the skin is dry and pungent. 

The bed should be guarded with a mackintosh-sheet and a 
blanket laid underneath the patient. The bed-clothes and the 
patient's night-dress being removed, he is covered with a blanket, 
and the skin slowly sponged over from above downwards with 
tepid water, or water at a temperature of 116° F., to which some 
vinegar has been added. A small portion of the body only should 
be exposed at one time, and the wet sponge passed two or three 
times over each part before drying it ; a hot bottle may be placed 
at the feet during this process. The effect is to reduce the tempe- 
rature, soothe the nervous system, and promote sleep, and it has a 
very refreshing effect in typhoid and other fevers. 

For the night siveats of phthisis, the sponging should be done 
quickly instead of slowly, and a fresh night-dress put on after- 
wards. 

Enemata. 

Pump Syringe. — There are several forms of instruments in 
use for the purpose of administering an injection into the bowel. 
Some are provided with a syringe of metal and a piston, with 
tubes of a suitable kind. Others, such as the Higginson's syringe, 
consist almost entirely of india-rubber. This latter is provided 
with a bulb which acts as a pump, to each end of which is fitted 
a tube of india-rubber, one of the tubes terminating in a bone 
nozzle with a shoulder-piece. The nozzle is introduced into the 
rectum, and the end of the other tube is sunk in the fluid to be 
injected; the bulb is then squeezed, and water is sucked in to the 
syringe, and injected into the bowel. This is a very simple form 
of syringe, but liable to get out of order and leak, especially if the 
tubes are made to screw on to the bulb. Messrs Ingram have 
manufactured one on the same principle, but all in one piece (fig. 57). 
The india-rubber is apt to get stiff and broken in cold weather, 
and should not be coiled up in a box, but hung up by the metal end 



APPLIANCES. 



209 



Before using any form of instrument a quantity of warm water 
should be pumped through it in order to make sure that it is in 
good order and thoroughly clean. 

It is usual to inject warm fluid at a temperature from 90° 
to 100° F. The patient 
should be placed at the edge 
of the right hand side of the 
bed, either lying on the back 
with the knees well raised, or 
lying on the left side with 
the knees drawn up. A 
mackintosh and folded towel 
should be placed under the 
pelvis to guard the bed. The 
fluid to be injected should 
be placed in a basin on a 
chair by the bed-side, and 
ascertained to be of the right 
temperature. The nozzle of 
the bone-tube should be 
warmed and smeared with oil 
or vaseline. The syringe 
should be filled, and the air 
ejected by squeezing the ball 
until the fluid begins to 
emerge through the nozzle, 
which may then be gently 
passed into the bowel in a 
direction slightly backwards 
up to the shoulder-piece. 
The fluid may then be slowly 
injected, taking care to desist 
before the end of the tube in 
the fluid is uncovered, other- 
wise air will be sucked in and 
injected. 

A towel or diaper should 
be pressed against the bowel 
as the tube is withdrawn, the 
patient being kept quiet for a 
time in order that the fluid 
may be retained for ten or more minutes. The night-stool or 
bed-pan should be always in readiness close by the bed-side. If 
any difficulty is experienced in introducing the nozzle into the 

o 





210 A MANUAL OF NURSING. 

bowel, or any resistance felt to the injection of the fluid, the 
nozzle should be slightly withdrawn and pushed on in a somewhat 
different direction. 

Ball Syringe (fig. 58). — When quite small quantities, such as a 
few ounces only, have to be injected, the vul- 
canised india-rubber ball with bone nozzle may be 
employed. Before injecting the fluid, the air 
should always be first squeezed out until the 
fluid appears at the orifice. The ball syringe 
is useful for nutrient injections, or medicated 
fluids. 

Fig. 58.— Ball Long Rectal Tube. — In cases of faecal impac- 
Syrmge. Hon, or intestinal obstruction, when the use of 

the ordinary enema is ineffective, the fluid may have to be injected 
with the long tube. This is used by the medical attendant, but 
the nurse may be required to employ it. It is a long tube of 
india-rubber, one end of which can be fitted on to the nozzle of 
the enema syringe. The tube is previously softened in hot 
water, and slowly inserted into the rectum; as it is passed further 
and further the end may be guided to the left side, but no force 
should be used, as there is danger of damaging the bowel. It 
is not always easy to introduce it, and when it seems to be 
travelling on it may really be coiling upon itself. When it has 
been introduced as far as it will go easily, the fluid may be injected. 
Simple Enema. — Warm water, soap and water, oatmeal-gruel, 
or barley-water are commonly used in ordinary cases, and the 
amount of fluid to be injected will depend partly on the age of the 
patient, and the nature of the case. For infants one ounce, for 
children from four to ten ounces, will be sufficient; while for adults 
two or more pints may be injected. 

Oil Enema. — Olive or linseed oil injections are more effectual 
in softening hardened masses impacted in the bowel ; one and a 
half to two pints of oil may be used. In cases of intestinal 
obstruction, the injection may be given with the pelvis raised above 
the level of the head and shoulders, and the enema should be 
retained as long as possible. 

The fluid should always be carefully warmed to a tempera- 
ture of 80° to 100° F.j and oil may be heated by surrounding 
the basin containing it with quite hot water, until the oil is 
sufficiently warm. 

Medicated Enemata. — Astringent or sedative fluids are often 
used for injection in diarrhoea, in haemorrhage from the bowel, or 
to give relief from pain. The amount of fluid injected is consider- 
ably smaller than for aperient enemata. Two to four ounces of 



APPLIANCES. 211 

water containing the astringent is sufficient, or the same quantity 
of starch mucilage with half a teaspoonful of laudanum may be 
used as an opiate. 

Salt Injections, in the proportion of one tablespoonful of salt to 
a pint of gruel, are useful for destroying thread worms in the 
rectum. 

Turpentine Injections should contain from half to one ounce of 
turpentine, with a pint of gruel or barley-water. The instrument 
should be afterwards cleansed by a stream of soap and water. 

Nutrient Enemata. — This mode of feeding is of the greatest 
value in prostration, or when vomiting, or disease of the stomach 
prevents nutrition being carried on by the mouth. After profuse 
haemorrhage, long and severe operations, or during temporary 
unconsciousness, the patient's life may be preserved by the 
injection of warm fluids or stimulants. 

The quantity injected should not exceed four ounces, and two 
or three ounces may sometimes be more easily retained. The 
injection should be warm (90° to 100° F.), and may be slowly 
administered with the ball syringe directly after a natural motion, 
or about an hour after the bowel has been washed out with a 
simple enema. If the injections have to be continued, the bowel 
is apt to become irritable, so that they should not be given more 
frequently than every four hours. 

The nutrient fluid should be about the consistence of cream, 
and may be composed of strong beef-tea, milk, eggs, gruel, meat 
extracts, or stimulants. Two or three ounces of beef-tea, the yolk 
of an egg, and half an ounce of brandy make a very useful 
injection. The food may be artificially digested before injection 
by the addition of a dessert-spoonful of the Liquor Pancreaticus 
(Benger) ; or pancreatised milk and beef extract may be used 
(see Appendix). 

Douches and Ice- Applications. 

Hot and Cold Douche. — The application of a stream of hot or 
cold water is beneficial for reducing inflammation in joint affections, 
and to relieve pain. The water may be poured from a can held 
at some height above the part by an attendant, or a tin can 
provided with an india-rubber tube may be placed at a suitable 
height, and the fluid directed where required (see Vaginal 
Douche). 

Vaginal Injections may be given with the Higginson's syringe. 
A special tube is provided with these instruments, made of hard 
rubber, which can be fitted on to the bone nozzle. The tube is 
from five to six inches long, and is pierced with holes along its 



212 



A MANUAL OF NURSING. 



sides towards the end of the nozzle; before use, it should be 
soaked in a solution of carbolic acid, and warmed by passing a 
stream of hot water through it. 

The bed must be arranged with a mackintosh and folded sheet, 
and the patient should lie near the edge on her back with the 
knees drawn up, with a round bed-pan or bed-bath underneath 
her. 

The tube being oiled, the nozzle is passed under the right knee 
into the vagina in a direction upwards and backwards. Care 
should be taken that the tube is filled with the solution, and free 
from air before injection, and the injection should be stopped before 
the vessel is empty. 

TJie Vaginal Douche may be given in a similar manner. An 
instrument may be obtained for those who require its constant 
use, which can be managed without assistance. It consists of a 
tin reservoir or pail containing from two to four quarts, from the 
bottom of which comes a long tube furnished with a stop-cock 
and a perforated nozzle. The reservoir is filled with the fluid to 
be injected, and placed on a shelf a few feet above the patient. 
When the fluid has entered the tube, the nozzle may be inserted, 
and the patient can control the flow by using the stop-cock. 
Vaginal injections may be used at a temperature varying from 

70° to 100° F., and the tem- 
perature of the hot douche 
should be from 100° to 115°. 
For antiseptic purposes carbolic 
acid of the strength of 1-40 to 
1-80, or one teaspoonful of 
Condy's fluid to a pint of water 
may be employed. 

The vaginal tube, preferably of 
glass, should not be perforated at 
the extremity if the fluid is not 
intended to enter the uterus. 

Nasal Douche (fig. 59). — An 
india-rubber tube a few feet in 
length is required, provided with 
a weight at one end and a nozzle at the other. The fluid to be 
used is placed in a bowl on a ledge at some distance above the 
patient's head. The weighted end is sunk in the fluid, and the 
fluid started running by sucking the nozzle end, or pinching 
the long tube to exhaust the air, when there will be a continuous 
stream kept up. The patient should be directed to hold the 
nozzle in the nostril, lean over a basin, and keeping the mouth 




Fig. 59. —Nasal Douche. 



APPLIANCES. 



213 




Fig. 60.— Ice Basr. 



open to breathe through it and not through the nose. The fluid 
should enter one nostril, and running round the back escape from 
the other. This process 
requires some practice to 
perform efficiently. 

Ice Bags (fig. 60).— 
India-rubber bags are 
made for the application 
of ice, the shape varying 
according to the part to 
which the ice has to be 
applied, or an efficient 
substitute for an ice bag 
may be made with a 
common bladder. 

Ice Caps (fig. 61) are 
also used for applying 
cold to the head, con- 
sisting of coils of tubes 
through which iced water is made to percolate by means of a 
syphon, and is received into a bucket at the bedside. Metal tubing 
(Leiter's) may be used in 
the same manner. This 
tubing is pliable, and can 
be adapted to the part, the 
water passing through by 
the syphon action, and it 
has the advantage of being 
less disagreeable to the 
patient than the india- 
rubber apparatus. 

Ice should be kept in 
large lumps, from which 
pieces are separated by 
a pin or needle. To pre- 
vent its melting too rapidly, 
it should be kept in a 
refrigerator or in a cool 
room. It is best to wrap 
it in flannel, and place it 




Fig. 61.— Ice Cap. 



in a receptacle so arranged that the 
water can drain off as soon as the ice melts, and not to keep it 
standing in the water which has melted off. 
Ice Poultice. — See Appendix B. 



214 A MANUAL OF NURSING. 



Poultices and Fomentations. 

POULTICES. — The application of heat and moisture to the 
surface of the body is best effected by a poultice. Various 
substances are used for this purpose, of which linseed-meal and 
bread are the best. 

Linseed Poultice of crushed meal. A bowl and spatula or 
knife are required, which should previously be heated by being 
dipped in boiling water. A sufficient quantity of boiling water 
is put into the basin to make the poultice of the required 
size ; the linseed-meal is then quickly added little by little with 
one hand, stirring well the whole time with the spatula or knife 
until the right consistence is attained. 

The mass should not be too firm or too sloppy, but sufficiently 
moist to turn out of the basin without sticking to the sides. The 
poultice is evenly spread on a piece of warmed linen, lint, or 
teased-out tow. The extra margin is then turned in over the 
edges. A single layer of thin muslin may be spread over the face 
of the poultice if not required to be next the skin. The heat of 
the poultice should be tested with the back of the hand before 
being placed on the body, and should be as hot as can be comfort- 
ably borne. An external covering of cotton-wool, lint, or water- 
proof should be adapted, and the whole well secured in position by 
a bandage, napkin, or binder. The essential points in giving a 
poultice are that it should be hot and of the right consistence ; it 
is necessary that the water should be boiling, that the implements 
should previously have been heated, and that there should be no 
delay in applying it when made. If the poultice has to be carried 
from one room to another, it should be placed on a hot plate and 
covered over with a napkin. To make it of the right consistence 
too much water should not be used, but if too little is added it will 
be hard and cold, and the thickness should not be out of propor- 
tion to the size, since the weight pressing on a tender or inflamed 
part will in itself cause pain. The poultice should be removed 
before it gets cold, and a fresh one applied if necessary every four 
or six hours, but the old one should not be removed until the new 
one is ready. When discontinued, the skin should be dried with a 
soft towel, and covered with flannel or cotton-wool. 

A Jacket Poultice is often used for chest-affections. A large 
piece of linen should be cut out of sufficient size to cover the back, 
sides, and front, and after the poultice has been spread it is placed 
round the chest, and the edges secured with safety-pins over the 
shoulders, and underneath the arms. It may be made in two 
pieces for an adult, or in one for a child. 



APPLIANCES. 215 

Bread Poultice. — Coarse bread-crumbs from stale bread should 
be added to boiling water in a basin and well stirred. The basin 
should be covered up and placed by the fire for a few minutes. 
The water must then be drained off, and fresh boiling water added, 
and again poured off, when the poultice may be spread and 
applied. 

This form of poultice is very soft, and well suited for small 
applications to tender parts, but does not retain the heat so well 
as the linseed-meal. An excellent poultice is made by mixing 
equal quantities of linseed-meal and bread-crumbs. 

Charcoal Poultice. — This is often required for foul and slough- 
ing parts, as in gangrene or decomposing ulcers. A bread poultice 
is prepared to which a quarter to half an ounce of finely powdered 
charcoal or more, according to the size required, is gradually added 
and well mixed, or the charcoal may be added in the proportion of 
half an ounce to four ounces of linseed-meal and bread in equal 
parts. The surface of the prepared poultice should be sprinkled 
with fine charcoal before application. 

Yeast Poultices are useful for wounds or ulcers, and the 
following proportions may be used : — Two ounces of beer yeast 
should be mixed with an equal quantity of hot water, a quarter of 
a pound of flour, linseed-meal, or fine oatmeal is gradually stirred 
in, and heated until it rises, and is sufficiently hot ; an earthenware 
vessel should be used for its preparation. 

Mustard Poultices may be made of any strength. The direc- 
tions in the British Pharmacopoeia require equal parts of 
mustard in powder and linseed-meal. The meal should be mixed 
with boiling water and the mustard added whilst stirring. A less 
proportion of mustard should be added for patients with delicate 
skins, and the poultice may be applied for a longer time. It 
should be spread on a cloth or on brown paper, and a layer of 
muslin may be placed over it. 

A redness of the skin accompanied by a burning sensation is 
produced after a time ; but there is a great difference in the deli- 
cacy of the skin in individuals ; a strong mustard poultice should 
not therefore be left on, especially in the case of children, without 
ascertaining its effect. A corner should be turned down after a 
time, and the skin examined to prevent the production of a blister. 

FOMENTATIONS and STUPES. — These are convenient 
methods of applying warmth and moisture to the skin, and have 
the advantage of cleanliness and simplicity. A piece of coarse 
flannel about a yard square should be folded to the size required 
and placed in a basin of boiling water. It is then put on a towel, 




216 A MANUAL OF NURSING. 

and the ends of the towel twisted tightly in contrary directions until 
the water is thoroughly squeezed out of the flannel, which is then 
carried inside the towel to prevent its cooling and applied. The 
outer surface should be guarded by several folds of dry flannel 
to avoid wetting the clothes. 

The fomentation will require changing every half-hour, or 

more often, if great heat 
has to be constantly kept 
up, and the second hot 
flannel should be ready 
before the first is removed. 
Wringers (fig. 62) are 
used in hospitals where 
fomentations are constantly 
required. They consist of 
coarse towelling or canvas 
provided with a wooden 
Fig. 62.— A Wringer. r °d- a t each end, to take 

hold of while wringing 
out the boiling water, and prevent burning the fingers. 

Poppy Fomentation. — Break up two poppy heads, and boil 
them in two pints of water until the quantity is nearly reduced 
to one pint, then strain, and soak the flannel in the boiling fluid. 

Laudanum Fomentation. — When the flannel has been wrung 
out of the hot water, the surface should be quickly sprinkled with 
half an ounce or an ounce of laudanum before applying to the skin. 
The Turpentine Stupe is used for counter-irritation, and is 
prepared in the same way as the laudanum fomentation, three or 
four teaspoonfuls of turpentine being used instead of laudanum, 
and well distributed over the surface of the flannel by wringing 
it out ; care should be taken that it does not blister the skin. 

Spongio-Piline is a thick, soft material, one surface of which is 
covered with waterproof to prevent evaporation. It may be used 
for fomentations instead of flannel. 

Counter-Irritation — Blisters, 

COUNTER-IRRITATION.— Various means are employed to 
produce redness of the skin, and to assist in relieving pain and 
inflammation in the deeper parts, amongst which are mustard 
applications and turpentine stupes. 

Mustard Leaves. — A very convenient substitute for a mustard 
plaster can be obtained in the form of a leaf or thin sheet of paper 
prepared with mustard. The leaf is soaked for a few seconds in 
cold water, or tepid water in winter, applied wet to the skin, and 



APPLIANCES. 217 

secured by a napkin or bandage. The action is very rapid, and 
sometimes too severe. 

Liniments are also used for this purpose, the stronger ones 
requiring care in application, such as croton oil, belladonna, 
iodine, &c. These should be painted on with a brush and not 
rubbed in, and the fluid used sparingly at first over a small 
surface to test its effect. 

Blisters are a powerful form of counter-irritation, the cuticle or 
superficial part of the skin becomes raised from the part beneath 
by an effusion of fluid or serum, drawn from the blood by the action 
of the blistering material. 

There are two methods in common use. The application of 
blistering ointment spread on stiff paper or leather to form a 
plaster, the Emplastrum Lyttse ; and painting the part with 
blistering fluid. 

The plaster may be secured by a bandage or handkerchief, a 
less painful method than using sticking plaster, which drags when 
the blister rises, and adheres to the skin and hairs round the tender 
region. In order to vesicate, the plaster should remain on from 
eight to ten hours ; three or four hours will suffice to produce 
redness to the skin. 

AYhen vesication has been produced, the plaster should be 
gently removed without breaking the blister. 

Dressing Blisters. — The vesicle should be opened at the most 
dependent part by sharp-pointed scissors, and the fluid allowed 
to escape into a test-tube or glass vessel and kept for examina- 
tion. 

The surface may then be dressed with a fold of lint covered 
with sweet oil or ointment, a thin layer of cotton-wool being 
secured over it by a bandage. A warm linseed-meal poultice is a 
comforting application after severe vesication ; but if it is desired 
to keep the blister from healing savin ointment should be applied 
on lint instead of simple dressing. 

Leeches — Cupping. 

LEECHES are used to remove a small quantity of blood. 
Before applying them the skin should be washed over with warm 
water and dried, and the leech should also be wiped with a soft 
cloth. 

To apply the leech, hold it by its larger end in the folds of a 
cloth, and allow the smaller extremity or head to be directed over 
the skin in the necessary region. When the head has taken hold 
the body may be released, and the leech will adhere to the skin 
by its sucker. Another method of application is by means of a 



218 A MANUAL OF NUKSING. 

leech-glass, or an ordinary wine-glass or test-tube may be inverted 
over the part with the leech inside until it has begun to bite. 

If there is difficulty in getting the leech to bite, a little milk or . 
sugar and water may be first smeared over the skin. 

The leech should be allowed to drop off when it has sucked 
its fill, and not be dragged off. If the leeches are likely to be 
used again they should be sprinkled with a little salt until they 
have disgorged the blood, washed, and kept in a glass or earthen- 
ware jar with a perforated cover, filled with fresh water. The leech 
bites should be washed with warm water, dried, and covered with 
cotton-wool, which will in most cases stop the bleeding. 

If necessary, the bleeding may be further encouraged by apply- 
ing a hot fomentation. 

To Arrest Bleeding from Leech-Bites. — The bleeding may be 
so persistent as to produce exhaustion. Patients, and especially 
children, should not be left for the night after the application of 
leeches, until all bleeding has ceased. If the bleeding is over a 
hard surface of bone, it may be easily stopped by firm pressure 
with a pad of lint or cotton-wool held on or bandaged on for a few 
minutes. 

If there is difficulty in stopping the bleeding, a surgeon should 
be summoned, pressure being applied until his arrival. 

CUPPING is a method of abstracting blood locally, and there 
are two ways of applying it — wet cupping and dry cupping. Wet 
cupping is only practised by the surgeon; several incisions being 
made in the skin, and the blood drawn into a cup by atmospheric 
pressure. Dry cupping is used when it is desired to draw the 
blood into the superficial tissues without shedding it. In either 
case, the cups are applied after the same manner. 

The part to be cupped should be previously sponged with warm 
water, and the spot chosen should be as flat as possible. The cups 
are of different sizes, and made of glass. A few drops of spirit are 
placed in the cup, which is then shaken so as to moisten the sides, 
the excess of spirit is thrown out, and a small piece of blotting- 
paper moistened with spirit is set alight and dropped into the 
cup. When the spirit inside flares up the cup is immediately 
turned over, and the edges firmly applied to the skin. The flame 
immediately becomes extinguished, and the air being exhausted 
the skin in the interior rises up into the cup, forming a consider- 
able swelling ; or if incisions have been made by the scarifier, the 
blood trickles out and slowly fills the vessel. To remove the cup, 
one edge should be raised, and the skin firmly depressed with the 
thumb until the air gains admittance, when it can be easily removed. 



APPLIANCES. 219 

If blood is drawn, it should be received into a measure without 
spilling it, and the amount noted. The wounds may be sponged 
and covered with lint or plaster, or allowed to bleed further into a 
hot poultice. 

Ointments and Suppositories. 

OINTMENTS are used for application to raw surfaces and 
skin affections. They should be evenly spread by a spatula or 
knife over the smooth side of strips of lint cut to a suitable shape ; 
they may be spread over the affected part, and secured by a thin 
bandage. 

Inunction may be used for parasitic affections, such as the itch 
(see Scabies), or for introducing mercury into the system. For 
the latter the mercurial ointment in the amount prescribed must 
be rubbed into the skin of the arm-pit, thigh, or abdomen. A 
flannel bandage should be applied to cover the part afterwards. 
Before repeating the inunction the skin should be washed over 
with soap and water. 

Symptoms of Mercurial Poisoning, such as sore gums, tenderness 
in them on biting, or salivation, must be watched for, and the 
application stopped until the facts have been reported to the 
medical attendant. 

SUPPOSITORIES, MEDICATED.— These are used for the 
purpose of introducing drugs of different kinds into the rectum. 
The drug is mixed up with cacao-butter, or some fatty material 
which is easily dissolved, and the ingredient becomes absorbed 
into the circulation. They are shaped like a cone, and may be 
introduced by the patient himself, inserting the small end first, and 
pushing it in well up into the bowel. If necessary, the nurse can 
pass it, by previously oiling one finger and pushing the suppository 
well beyond the sphincter, the patient lying on the left side with 
the knees well drawn up. 

Nutrient Suppositories may be made of soluble meat or of 
meat peptone, and the outside should be oiled previous to intro- 
duction. 

Applications to Eye, Ear, and Tliroat. 

EYE-DROPS. — To be efficacious, the fluid must have access to 
the surface of the eye-ball underneath the lids. The patient, 
sitting in a chair, must throw the head well back, the under eye-lid 
is then drawn down with the finger, and the upper lid drawn up 
with the thumb, and a drop is placed in the eye at the inner 
corner near the nose ; the patient's head is then tilted over so that 



220 A MANUAL OF NURSING. 

the drop runs across the eye while the lid is still held up, and the 
fluid bathes the surface of the eye-ball. The fluid may be dropped 
in with an eye-dropper specially constructed, or a glass rod or 
earners hair brush may be used for the purpose. 

Eye-Lotions or Collyria ought generally to be applied warm, 
absorbent cotton-wool being used as a sponge and destroyed after- 
wards. In inflammatory and purulent discharge from one eye, 
great care should be exercised to prevent the disease from being 
conveyed to the sound eye, or to the eyes of others by the nurse's 
hands or by the dressings. 

EAR-SYRINGING.— A syringe of suitable size should be 
used, capable of containing several ounces of fluid. Two slop- 
basins are required, one to hold the fluid, and the other to receive 
it as it returns from the ear. To prevent the water from running 

down the neck, a trough is used which 
fits on to the ear, and is held in position 
by a spring passing over the top of the 
head, or by a string round the ear 
(fig. 63) ; in addition, a towel should 
be closely fitted round the neck. Warm 
water is drawn into the syringe, and 
the air discharged before introducing 
the nozzle, which should be kept 
applied at the upper part of the orifice, 
while the upper part of the ear is 
drawn gently upwards and backwards. 
The fluid returns along the floor of 
Fig. 63.— Trough for Ear- the canal, and is directed by the 
byrmgnig. trough into a basin, which can be held 

by the patient ready to receive it. Attacks of coughing or giddi- 
ness are apt to accompany syringing of the ear, but soon pass off. 
When there is hard wax blocking up the canal, it may be softened 
by introducing a drop or two of warm olive-oil or glycerine 
previous to using the syringe, when it may be more easily removed. 
In placing cotton-wool in the ear to soak up discharges of 
matter, the plug should be placed in the fold just outside the 
orifice, and not inside the canal. 

THROAT APPLICATIONS.— Gargles are employed for wash- 
ing the tonsils and back of the throat. About half an ounce of 
the fluid is taken into the mouth, the head being held well back, 
and moved from side to side so as to wash the fluid against the 
back of the throat, or the breath is expired through the fluid, 




APPLIANCES. 221 

causing it to bubble and extend to the adjacent parts. Gargling 
should be repeated several times. 




Fig. 64.— Hand Spray-Producer. 



Sprays are in many respects more convenient than gargles, and 
are more pleasant for cases of ulcerated or painful sore throats. 
The spray-producer is a simple contrivance by which fluids can be 
pumped in the form of a fine spray on to the tonsils and back 
of the pharynx. The fluid is introduced into the glass jar, and 
the apparatus worked by pressing the india-rubber hand ball 
(fig. 64). 

Antiseptic Spray Producer. — The Spray Producer commonly 
in use is a steam apparatus. A solution of carbolic acid (1 in 
20) is placed in the glass bottle, and hot water is poured into 
the boiler, the spirit-lamp being lighted so that the water 
boils before the spray is wanted. The steam mixes with the 
carbolic acid when the spray is set going, and the nurse should 
ascertain beforehand that the machine is in thorough work- 
ing order. Two spray-producers may be required in special 
cases. 

Inhalations. — These are useful for the appplication of remedies 
to the air passages in laryngeal and bronchial affections, or for 
asthmatic seizures. Steam is often used by itself, or the vapour 
is rendered sedative, stimulant, or antiseptic by the addition of 
solutions to the water. 

Inhalations may be managed in a simple manner by covering over 
the mouth of a jug containing boiling water with a towel or napkin, 
leaving an aperture of sufficient size to admit the mouth and nostrils. 



222 



A MANUAL OF NURSING. 



The patient should sit with the head bent over the jug, and 
gradually bring the mouth near to the orifice through which 
the vapour is issuing. The breathing should be quiet and 
natural, and after six or seven inspirations the face should be 

withdrawn for half a 
minute, and the process 
repeated at intervals for a 
period lasting from ten to 
twenty minutes. The best 
time for inhaling is before 
bed-time, and the patient 
should avoid going out, or 
^? into a cold room, for some 
02 time afterwards, if it has 
°3 been performed in the 
g daytime. 

< Vessels of various forms 
b have been devised for in- 
^ haling ; the simplest being 
an earthenware vessel pro- 
vided with a mouth-piece 
and a tube issuing from the 
side to admit the entrance 
of air. The vessel is filled 
half full by removing the 
mouth-piece and pouring 
in hot water containing the 
solution for inhalation, or 
else a sponge is fitted into 
the mouth-piece and the 
required number of drops 
tf poured on to it. 
£ The steam passes through 
the sponge, and is saturated 
with the solution. 

Fuming Inhalations are 
used in spasmodic asthma, 
either in the form of 
cigarettes, nitre-papers, or 
powders. The papers may 
be placed on a plate and 
allowed to smoulder, the smoke being directed towards the 
patient's mouth and nose. When the fumes of powders are 
inhaled they may be conveniently directed in the following 




APPLIANCES. 223 

manner: — A sheet of foolscap paper is rolled into a sugar-loaf 
form, and the broad end placed over the plate on which the 
powder is burning. The upper end of the cone is opened suffi- 
ciently to allow a stream of smoke to issue forth under the 
patient's nostrils. 

Bronchitis Kettle. — An ordinary kettle may be furnished with 
a steam-pipe, and kept boiling on the fire, or a special kind may 
be procured. Some are provided with a spirit-lamp, and may be 
also used for the vapour-bath (fig. 66). 



CHAPTEE XY. 

The Antiseptic Treatment — Bandaging. 

The Antiseptic Treatment— Method— Importance of Cleanliness— 
The Dressings — Bandaging — The Roller Bandage — Rules for 
Bandaging — Simple Spiral — Reversed Spiral — Figure-of-8 — 
Spica — Capeline— Leg Bandage — Finger Bandage — Stump Band- 
age — Many-tailed Bandage— T-Bandage — Slings — Pads — Sand- 
Bags. 

THE ANTISEPTIC TREATMENT.— This method, which is 
almost universally adopted in the treatment of wounds, was 
introduced by Sir Joseph Lister, and is based upon the principles 
of the Germ-theory, namely, that the putrefaction in wounds 
exposed to the air is not due to the air itself, but to the solid 
particles floating in it in the form of dust. This dust may be 
easily observed in the track of a sunbeam as it passes through a 
room, and may be shown by the aid of the microscope to contain a 
very great number of organisms — bacteria — varying in their size, 
vitality, and virulence, according to the unhealthiness of the 
surroundings in which they have been developed. 

These organisms are the germs or spores, which, when introduced 
into wounds, cause putrefaction, inflammation and suppuration, 
erysipelas, pyaemia, tetanus, and the like ; or when inhaled into 
the interior of the body, may give rise to one or other of the 
infectious fevers, such as scarlet fever or diphtheria, according to 
the particular germ present in the atmosphere. 

A wound which is kept entirely free from all organisms will 
heal without fail, and the best antiseptic method is that which 
succeeds in excluding these agents in the most effective manner. 

The completeness with which these minute particles can be 
prevented from entering a wound must necessarily be limited, 
hence endeavour is also made to destroy any germs which may 
have succeeded in gaining an entrance. For this purpose, certain 
fluids found by experiment to be detrimental to germs are used. 

Inasmuch as the secretions and discharges from the wounded 



ANTISEPTIC TREATMENT. 225 

surfaces, or blood left in the wound after operation, are a medium 
in which germs are able to flourish and multiply with activity, 
it is also a great object in the successful treatment of wounds to 
make and preserve the wounded tissues in as dry a state as possible. 

Antiseptic Method. — Although the methods, materials, and 
fluids used by surgeons differ considerably, the principles are the 
same, and everything and everybody connected with the operation 
has to be subjected to a process of purification. 

Cleanliness is the first and most important virtue, and it 
cannot be too strongly insisted on. It is useless to surround the 
wound with spray-producers, and to employ all the paraphernalia 
of antiseptic dressings and fluids, if the patient's skin has not been 
previously cleansed, or if the hands and nails of the nurse or 
assistant have not received the necessary attention, or if the room 
is full of impurities. 

In the case of operation it will be the nurse's duty to see 
that the room has been thoroughly cleaned, and all unnecessary 
furniture, or articles that are likely to harbour dust, removed. 
She will also be expected to ascertain that the patient is thoroughly 
clean, and that the garments worn at the operation are clean. 

The hands of all those assisting at the operation, the instruments, 
sponges, and everything required to come into contact with the 
wound, will have to be rendered aseptic, and the skin in the neigh- 
bourhood of the part to be operated on must be thoroughly purified. 

The nurse should prepare a basin of hot water, soap, and a nail 
brush ; after the hands have been thoroughly cleaned, they should 
be dipped in a solution of perchloride of mercury (1 to 2000)or 
in carbolic solution (1 to 20). Before the operation the patient's 
skin should be scrubbed over with soft soap, and then shaved, the 
parts being then washed over with the perchloride or carbolic 
solutions. 

In some cases it may be necessary to employ a preliminary 
washing with turpentine. Mackintosh sheets covered with hot 
carbolised towels should be spread over the blankets covering the 
patient, and arranged so as to surround the part to be operated on. 

If the spray is to be used, this should now be turned on before 
the operation is commenced. 

The instruments are prepared beforehand, and are placed ready 
in a tray containing the carbolic solution (1 to 20). 

Sponges should be wrung out in carbolic solution (1 to 40), 
during the operation, and be thoroughly cleansed in 1 to 20 
afterwards, and kept in a jar containing the same solution. 

The Dressings. — After the wound and the surrounding parts 
have been thoroughly cleansed from blood, &c, with an antiseptic 

P 



226 A MANUAL OF NURSING. 

solution, the soiled towels are removed, and a clean towel wrung out 
in perchloride of mercury (1 in 2000) should be placed around 
the wound. The dressing is then applied. It generally consists 
of layers of double cyanide gauze, wrung out in carbolic (1 in 40),* 
and over this some antiseptic wool is placed, and then a bandage. 

Before applying the gauze to the wound, the amount required 
for the dressing should be placed in a basin of boiling water. It 
should then be squeezed tightly, and shaken loosely out before use. 
The gauze must be covered by layers of salicylic, or other anti- 
septic wool, and over this a light bandage of carbolic gauze. If 
pressure is needed, a flannelette bandage should be applied over all. 

Bandaging. 

The art of bandaging can only be learned by practice, but there 
are certain fundamental principles which require to be known. 
The simplest form of bandage is the roller bandage, and this can 
be used for all purposes. 

EOLLER BANDAGES are made of unbleached calico, flannel, 
or domett. The length should be from six to eight yards long, 
and the width must be suitable to the part to be bandaged. 

For the head and upper limb, the width should be two and a 

half inches, for the lower limbs three 
inches, and for the trunk four inches, 
while for the fingers three quarters of 
an inch is sufficient. 

After the selvedges have been re- 
moved from the material, the bandage 
should be rolled up evenly and firmly 
Fig. 67. -Rolling the Bandage. by the handj Qr by ft winding mac hine. 

Starting at one end, the strip should be doubled upon itself into 
a small roll, and being held between the forefinger and thumb of 
each hand, it is rolled tightly up (fig. 67). 

Rules for Bandaging. 

1. Fix the bandage by two or three turns, one over the other, 
the outer surface of the roller being next the skin. 

* A cheap way of preparing an antiseptic dressing, if economy has to be 
studied, is to buy a supply of unmedicated gauze, costing about £d per 
yard, and to cut it in half- yard lengths. Get a large stone pickle jar with a 
closely-fitting lid ; fill the jar with mercuric chloride (1 in 500), and allow 
the gauze to soak for three days. The jars should be washed out, and 
the solution changed, once a week. 




BANDAGING. 



227 



2. Bandage from below upwards, and from within outwards, 
over the front of the limb. 

3. Use firm equable pressure throughout, 

4. Let each succeeding turn overlap two-thirds of the preceding 
one. 

5. Keep all the margins parallel, and let the crossings and 
reverses be in one line, and towards the outer aspect of the limb. 

6. End by fixing the bandage securely. 

In order to carry a bandage evenly up a limb, it is necessary to 




Fig. 68.— Bandaging the Foot : A, fixing ; B, reversing ; C, figure-of-8. 

use a combination of three different turns, — the simple spiral, 
reverse, and figure-of-8 (fig. 68). 

The Spiral Bandage is used only when the circumference of 
the part increases by very slight degrees, and consists in covering 
the part by a series of spiral turns, each overlapping the one below 
for about two-thirds of its width. 

The Reverse or Reversed Spiral is mostly used for bandaging 
a limb, owing to the enlargement of the 
limbs at the upper part. The bandage is 
carried up in the spiral form, but turns or 
reverses are made to accommodate it to 
the shape of the limb. To make these 
turns evenly, the bandage should be held 
quite slack at the moment of reversing, 
and not unrolled more than is necessary 
to make the reverse. All the reverses 
must be carried one above the other 
along the outer side of the limb, and should Fig. 69.— Figure-of-8 round 
never be made over a prominence of bone. Knee-Joint. 

Figure-of-8 Bandage. — The nature of this is indicated by its 
name, and it is useful for carrying a bandage over a joint, and for 
other purposes. The end of the bandage is made fast below the 




228 



A MANUAL OF NURSING. 



joint, or else the roll is carried on from the reversed spiral, up in 
front of the joint, behind the limb above the joint, and down 
again in front, and continued in the same manner until the joint 
is quite covered in (fig. 69). 

The Spica is an adaptation of the figure-of-8 bandage, and is 
useful for retaining dressings or applications to the groin, or for 
bandaging the breast. 

To bandage the groin, two turns should be made round the 
thigh of the affected side from within outwards, then the bandage 
is carried along the lower part of the groin over the dressings 
round the pelvis, and back over the lower part of the abdomen, 




Fig. 70.— Spica for the Groin. Fig. 71.— Bandage for Left Breast. 

crossing the former fold at the groin, and completing the figure-of-8. 
The remainder of the groin is covered in in a similar manner (fig. 70). 

To bandage both groins, the double spica is used, the bandage 
being used in a similar manner as for one groin, but is brought 
down from the opposite side of the pelvis to form a loop round 
the other groin. 

To bandage the breast — Two turns are to be taken round the 
waist, immediately below the breast in order to fix the bandage 
which is then carried under the affected organ and over the opposite 
shoulder ; then around the waist, so as to fix the former turn, and 
again under the breast and over the shoulder as before, until the 
part is sufficiently covered. The breast should be gently raised 
and supported while the bandage is being applied (fig. 71). 



BANDAGING. 



229 



The two breasts may be bandaged separately with the spica, or 
the many-tailed bandage may be used with advantage for retaining 
dressings in place. 

To bandage the head. — For ordinary purposes it is sufficient to 
carry two turns of the bandage round the forehead and occiput, 





Fig. 72. — Beginning the Capeline 
Bandage, viewed from behind. 



Fig. 73.— Capeline Bandage, viewed 
from the front. 



and then fastening the bandage behind one of the ears to carry it 
round the chin and over the top of the head. The bandage should 
be pinned or sewn where the turns cross one another, to make it 
secure. 

Capeline Bandage. — To cover in the whole head by this 
method, two rollers are fastened together as shown in fig. 72, one 
being rather longer than the other. The 
larger roll should always circle round the 
head, while the smaller should travel back- 
wards and forwards, the horizontal turns 
serving to fix the vertical. In beginning this 
bandage, it is necessary to keep the first 
circle low down close to the brows in front, 
and well below the occiput behind. The 
middle of the roller is laid against the fore- 
head, and the ends passed behind the occiput, 
where they are crossed. After this one end 
continues to encircle the head, fastening 
down at the forehead and occiput the other 
end of the roller which is carried backwards and forwards. The 
second head of the bandage starting from the occiput is brought 
over the crown to the bridge of the nose in the middle line, and 
after being fixed is brought back on the right of the mesial line 







^ 



Fig. 



74. — Bandaging 
the Eye. 



230 A MANUAL OF NURSING. 

to the occiput, where it is again fixed and carried forward to the 
left of the mesial line. This arrangement is repeated until the 
whole of the scalp has been covered over (fig. 74). 

To bandage the leg, one or two turns are carried round the foot 
close to the toes, and the remainder of the foot covered by the 
reverse turns; a figure-of-8 is then made round the ankle, leaving 
out the heel. The bandage is carried up the leg by reverse turns 
to the knee, where the flgure-of-8 is again used, and the thigh 
covered by the simple spiral or reverse turns if necessary. 

To bandage the finger. — A bandage of half or three-quarters of 
an inch should be used. One or two turns are made round the 
wrist, leaving out a loose end ; the bandage is then brought over 
the back of the hand, and taken in a series of spirals to the tip of 
the finger which it surrounds. A series of regular spirals are 
made in an opposite direction to the root of the finger again, and 
the bandage is then taken across the back of the hand, and tied 
round the wrist with the loose end left on commencing. 

To bandage a stump. — This is first fixed by simple turns below 
the nearest joint, and brought downwards in figure-of-8 round the 
limb till the end of the stump is reached, which is next covered in 
by oblique and circular turns carried alternately over the face of 
the stump and round the limb. If a double-headed roller is used it 
may be applied in the manner directed for the capeline bandage. 

Many-tailed Bandage. — This form of bandage is useful for 
retaining dressings on the limbs, abdomen, or breast, so that the 
dressings can be renewed with as little disturbance to the patient 
as possible. 

For a limb it is only necessary to take a piece of bandage the 
length of the limb, and lay across it strips of another roller, long 
enough to go once and a half round the limb. These are tacked 
at the centre at right angles to the central strip, so as to overlap 
one another by one-third. The long central piece is then placed 
behind the limb, and the cross pieces folded round separately, 
commencing from below, and crossing one another in front. 

The many-tailed bandage for the abdomen is often used after 
ovariotomy or abdominal section, and should be made of flannel, 
the strips being cut of a length suitable for the patient. 

The T-Bandage is useful for retaining dressings on the peri- 
neum. It is formed of one piece of bandage to go round the 
waist, and fasten by tying or a safety-pin; to the centre is 
attached another piece to pass between the thighs, being fastened 
in front to the circular portion. This vertical piece may be con- 
veniently split towards the end, so as to pass on each side of the 
scrotum, and is useful for keeping dressings upon the groins. An 



BANDAGING. 231 

extemporary T-bandage may be formed from an ordinary roller by 
fastening it round the waist with a knot in front, and then carry- 
ing the end between the thighs, on one side of the genitals, looping 
it over the circular band behind, and bringing it forward again on 
the other side of the genitals to fasten in front. For females an 
ordinary diaper may be used as the vertical portion. 

Slings, Pads, and Sand-Bags. 

SLINGS. — A sling for the hand or wrist may be formed by a 
large handkerchief folded into the shape of a broad cravat, which 
can then be knotted round the neck, so as to support the hand 
rather above the level of the elbow. 

Slings for the Arm. — A large handkerchief must be folded into 
a triangle, and placed with the base beneath the wrist. The end 
of the sling in front of the affected arm is then passed over that 
shoulder to meet its fellow at the back of the neck. The apex of 
the triangle may be brought round the elbow and pinned in front. 

Pads for splints may be made of tow carefully teased out, or of 
cotton-wool. The covering should be of soft cloth, muslin, or old 
linen. The pad should be made to slightly overlap the splint in 
all directions. Disused pads should be burnt, and the splints 
washed. 

Sand-Bags should be kept in readiness to support injured limbs 
or cases of fracture. The covering may be of soft leather or 
strong calico. The sand should be fine and well dried, and the 
bags need only be three-quarters filled. 



CHAPTER XVI. 

Artificial Respiration — Application of Electricity — 

Massage. 

Artificial Respiration — Clinical Thermometer — Hypodermic In 
jection — Batteries — Application of Electricity— Massage or 
Rubbing. 

Artificial Respiration. 

Artificial Respiration is required for cases of suspended 
animation after hanging, drowning, suffocation from noxious 
gases, or for failure of respiration in chloroform inhalation. As- 
phyxia, or deficient oxygenation of the blood, is the main cause of 
the condition, and the patient lies in a state of insensibility, the 
respiratory movements are absent, the pupils often widely dilated, 
and the countenance and extremities livid or dusky pale. The 
heart may continue to beat for some time, and if the respiratory 
movements are artificially kept up, life may be saved. In cases 
of this description no time should be lost in carrying out the 
movements. 

Sylvester's Method (fig. 75). — Loosen all clothing about the 
neck, chest, and abdomen, and lay the person on his back on the 
ground. Clean the mouth of dirt, blood, &c, and extend the neck by 
throwing the head well back, a support being placed under the 
shoulders. If the chin be well kept up there is no need for the 
tongue to be drawn out of the mouth. Stand or kneel at the 
patient's head, and take hold of the arms at the elbows and carry 
them well upwards until the hands meet above the head. The 
chest walls are expanded by this movement and air enters the 
lungs as in inspiration. After a pause of two or three seconds, 
the arms are brought down against the sides and front of the 
chest, forcible pressure being made by the operator leaning over 
and bringing the weight of his body to bear on the chest for a 



ARTIFICIAL RESPIRATION. 



233 



moment. By this second movement the air is expressed from the 
lungs as in expiration. In three or four seconds the same series 
of movements are repeated, about fifteen respirations being made 
per minute. The process should be steadily continued for an 
hour or more before success is despaired of. 

When natural breathing is restored, the circulation should be 




Fig. 75.— Artificial Respiration : Sylvester's Method. 

encouraged by rubbing the limbs in a direction towards the heart, 
and warmth may be applied by a hot blanket, hot bottles, &c. 
Stimulants may be given by the mouth as soon as the patient is 
able to swallow, or if the collapse is great stimulant enemata may 
be administered. 



How to take the Temperature. 

Clinical Thermometer (fig. 76). — The bodily temperature is 
ascertained by this instrument, which is self-registering, and ranges 
from 90° to 112° F. Each degree is marked by a long line, and 



234 



A MANUAL OF NURSING. 



*£ 



divided into five equal parts, each part representing two "points" 
^^ or tenths of a degree. An arrow com- 

monly marks the average temperature of 
health or the "normal" temperature at 
98*°4. The index marks the temperature, 
and is either a small portion of detached 
mercury in the stem of the instrument, or 
else the whole column is cut off just above 
the bulb and makes its own index. 

Before taking the temperature, the index 
or mercury should be shaken down below 
the normal point, by a rapid swing of the 
arm, the stem being firmly held in the hand. 
The bulb is then introduced between the 
folds of the skin in the armpit, the elbow 
being drawn forward across the chest, or 
else it is placed under one side of the 
tongue, and the patient told to close the 
lips. The thermometer should be left in 
position for five minutes, and the tempera- 
ture read from the upper end of the index, 
and noted on the chart. Temperatures 
should be taken as far as possible at the 
same hours each day, the morning and 
evening being sufficient in most cases; the 
time of the day may be stated on the 
temperature chart. In a case of doubtful 
temperature, the thermometer should be 
introduced a second time. 

In some instances it is advisable to 
take the temperature in the rectum ; the 
bulb, being previously well oiled, should 
be introduced for about an inch and a 
half, and retained for five minutes. 
The thermometer should always be carefully cleansed after 

taking a temperature. 



Fig. 76.- 
meter. 



-Clinical Thermo- 
(Arnold&Sons.) 



Hypodermic Injections. 

Hypodermic Injections are usually given by the medical 
attendant himself, but in exceptional cases it may be necessary 
for the nurse to be able to use them. By this process a small 
quantity of fluid containing the drug in solution is injected under 
the skin, and becomes absorbed in a short time. 

The syringe (fig. 77) is a small glass cylinder marked to show the 



BATTERIES. 235 

number of drops. The fluid is drawn in by means of the piston, 
and the end of the cylinder is fitted with a hollow needle. To 
give the injection, the needle should first be ascertained to be clear, 
and the required number of drops drawn in by putting the point 
of the needle in the fluid and elevating the piston. The syringe 
should next be held with the point upwards and air-bubbles allowed 
to escape. A fold of skin is then pinched up on the back of the 




Fig. 77.— Hypodermic Syringe. (Arnold & Sons.) 

elbow between the finger and thumb, and the needle pushed 
quickly under the skin into the loose tissue beneath, when the 
fluid may be slowly injected. The needle is then withdrawn, and 
the finger placed over the puncture for a moment to prevent the 
fluid returning. After using, a stream of water should be drawn 
into the cylinder and the needle cleansed. 

Batteries. — Application of Electricity. 

Two forms of electricity are used in medicine ; one the 
continuous or galvanic current, the other the interrupted or 
faradic current. There are several different methods of obtaining 
the galvanic current, but one common form in use is composed of 
a metal and carbon immersed in a corrosive fluid. One arrange- 
ment of this fluid is called a " cell," and a combination of several 
of these cells forms a galvanic battery. For medical purposes a 
battery of from twenty to fifty cells is usually employed, and the 
number in use can be regulated at the will of the operator by 
contrivances which vary in the different kinds of machines (fig. 78). 

The Electrodes, or instrument by means of which the electricity 
is applied, are furnished with insulating handles to prevent the 
current passing through the operator. They" are provided at one 
end with a sponge, or else are covered over with wash-leather. 

The faradic or interrupted current is of instantaneous duration, 
and occurs only at the moment of making or breaking contact. 
The battery is connected with an induction coil, and a special 
mechanism is provided for automatically making and breaking the 
primary or the secondary current, a spark of electricity being 
produced at this point. The primary or the secondary current can 
be employed at will by a simple mechanism, the latter being by 
far the stronger of the two, and the strength of the current may 
be varied by the dial regulator. 



236 



A MANUAL OF NURSING. 



Before applying the current, the nurse should ascertain how to 
make the necessary wire connections of the battery in use, and 
how to regulate the strength of the current; and she should 
receive instructions as to the strength of the current to be applied 
in the particular case, and the duration of the application. 




Fig. 78. — Electric Battery with Electrodes. (Arnold & Sons.) 

If the electricity is to be limited in its action to the skin, the 
electrodes must be used dry and the skin powdered. Eut if, as is 
usually the case, the muscles and nerves are to be acted on, the 
skin must be thoroughly moistened by sponging over with water 
or salt water, and the electrodes kept moist during the whole time 
of the application. One electrode is usually held still at a certain 



MASSAGE. 



237 



part, while the other is moved gently to and fro over the muscle or 
group of muscles requiring to be stimulated. 

It is advisable always to commence with weak currents, gradually 
increasing the strength, and attention should be paid to complaints 
of pain, and to the muscular contractions produced by the applica- 
tion of the interrupted current. 

Great benefit often ensues in cases of paralysis from spinal or 
nerve disease, and in different forms of hysterical seizure, after the 
use of electricity. 

Massage. 

Massage or Rubbing is useful in restoring the muscular nutri- 
tion, in increasing the activity of the circulation, and in relaxing 
the stiffness and fixation of joints after injury. It can hardly be 
learnt without personal instruction, and this can usually be 
obtained at the various institutions and hospitals in which cases 
requiring massage are treated. 

The method is well described by E. M. in the Appendix of Dr 
Play fair's small work on The 
Systematic Treatment of Nerve 
Prostration and Hysteria : — 

"The patient lying in a blanket, 
begin at the feet by taking up 
the skin over the whole surface, 
and firmly pinching it, twisting (p 
the toes in all directions, knead- ^ 
ing the small muscles with the 
ends of the fingers and thumb, 
the large muscles of the legs 
with both hands, grasping alter- 
nately, frequently running the 
hand firmly up the leg and strik- 
ing the muscles very often with 
the side of the hand. Before 
commencing the kneading of any 
of the limbs, rub them freely with 

neat's-foot oil, and the more oil a patient's skin absorbs the 
sooner does she begin to make flesh. The hands and arms are 
manipulated in the same way, working upwards (fig. 79). The 
patient then lying flat upon her back with the knees up, the 
abdomen is first pinched all over, and then the abdominal walls are 
firmly grasped in both hands, one hand grasping as the other relaxes. 
This part of the body is finished by the hands being placed one on 
each side just below the ribs, and firmly drawing the flesh forward, 




Fig. 79. 



-Pinching Hand and 
Fore- Arm. 



238 A MANUAL OF NURSING. 

especially in the direction of the colon. Great attention should be 
paid to this part of the body, if the patient is troubled with indi- 
gestion. The patient now lying quite flat upon her face, commence 
at the nape of the neck, and pinch up the muscles on either side 
of the vertebrae, and along the whole of the back. Then place the 
two first ringers of the right hand, one on each side of the spine, and 
make a sweep downwards the length of the spine ; this should be 
done several times quickly. By working at tender spots longer 
and gently, the tenderness soon disappears. The patient must be 
taught to relax all the muscles of the body, and to lie perfectly 
passive, otherwise she will be much bruised, and the massage, 
instead of being a pleasure, will be a source of pain. Towards the 
end of the treatment, the limbs are exercised by movements of 
flexion and extension, especially the legs in the case of a patient 
who has not walked for years. In the first day or two, about 
twenty minutes is sufficient, but in about a week the patient is 
able to bear the full time (an hour and a half) twice a day, and 
she should then be left in the blanket for about an hour to rest 
quietly. " 



APPENDIX A. 
Cooking for Invalids. 

Gruel— Arrowroot— Toast and Water— Barley Water— Imperial 
Drink— Linseed-Tea — Rice Water — Lemonade — Orangeade — Egg- 
Flip — Liebig's Quick.Beef-Tea — Beef-Tea— Fluid Beef — Infusion 
of Raw Meat— Chicken Broth — Mutton Broth — Veal Broth — 
Meat Panada— Meat Jelly— Raw Meat Pulp— Peptonised Milk— 
Peptonised Beef-Tea — Tea — Revalenta Arabica — Chicken Cream 
— Caramel Custard — Potato Soup. 

Gruel. — One pint of gruel is made by placing two dessertspoonfuls of 
patent groats in a basin, and gradually stirring in two tablespoonfuls of cold 
water. Next pour the mixture into a stewpan containing 1 pint of boiling 
water, and let it boil for ten minutes, stirring it with a wooden spoon. 

If the gruel is for a cold, stir in a small pat of fresh butter and sweeten it, 
adding two tablespoonfuls of rum, if the patient is not feverish. 

A Cup of Arrowroot. — Ingredients, — A dessertspoonful of arrowroot, half a 
pint of milk. 

Time required, about a quarter of an hour. 

Take a dessertspoonful of arrowroot and put it in a small basin, add a 
dessertspoonful of cold milk, and stir smoothly into a paste with a spoon, 
adding a small teaspoonful of castor-sugar, according to taste. Take a small 
saucepan and put half a pint of cold milk in it ; put the saucepan on the 
fire, and when it is quite boiling pour it on to the arrowroot paste, stirring 
all the time. 

A more nourishing preparation may be made by adding to the mixture 
above described the yolks of two eggs, whipping it all well together. But 
the eggs should not be added until the mixture has cooled a little, or they 
will curdle. 

Toast and Water. — One quart of toast and water may be made by browning 
a crust of bread before the fire, and placing it in a jug, after which 1 quart 
of cold water is poured over it. The jug should then be covered, and allowed 
to stand aside for half an hour. 

Barley Water. — About half a pint of barley water may be made by taking 
2 ounces of pearl barley, and washing it well in several waters, after which 
a quarter of a lemon should be carefully peeled and placed in the jug with 
the washed barley and two lumps of sugar. Pour a oint of boiling water into 
the jug, and set it aside to cool. 

Imperial Drink. — Place a dessertspoonful of cream of tartar and two 
tablespoonfuls of powdered sugar in a jug. Pare the rind of a lemon very 



240 APPENDIX. 

thin, and cutting xt into little slices, place them in the jug. Next, pour 1 
quart of boiling water into the jug. Cover the jug and let it stand until it 
is cold, then strain it. 

Linseed-Tea is an excellent drink for many patients, but should not be 
given to those who are taking iron, lead, or copper as medicines. In order 
to make it, take 1 ounce of sugar, and the same quantity of whole linseed, 
adding four tablespoon fuls of lemon-juice, and half an ounce of liquorice-root. 
This mixture should be placed in a jug, and 2 pints of boiling water poured 
over it. 

The jug should remain for four hours in a hot place, after which the contents 
may be strained and used. 

Rice Water. — Ingredients. — Three ounces of Carolina rice, 1 inch of 
cinnamon stick, and sugar. 

Wash 3 ounces of Carolina rice in two or three waters. Put 1 quart of 
warm water into a stewpan, and place it on the fire to boil. Put the rice 
and 1 inch of cinnamon stick into the stewpan with a quart of boiling water, 
and let it boil for one hour. Then strain the rice water into a basin, adding 
sugar according to taste, and when cold it will be ready for use. 

Lemonade. —After having placed the kettle on the fire, take two lemons, 
and after wiping them clean, peel them very thinly. Cut off all the pith or 
white skin, and cutting up the lemons into thin slices, take out all the pips, 
and put the slices and half the rind of the lemons into a jug, adding about 
1 ounce of loaf-sugar, according to taste. Pour one pint and a half of 
boiling water on to the lemons in the jug, and cover it over. Put it aside 
to cool. When quite cold, the lemonade should be strained into another jug 
ready for use. 

Time required, about two hours. 

Orangeade. — Pour boiling water on a little of the orange-peel, covering it 
up. Boil some water and sugar to a thin syrup, and skim it. Squeeze the 
juice out of the oranges, and mix it with the syrup and infusion of peel, but 
not until both are cold. Add as much water as will make a rich sherbet, 
and strain it through a jelly-bag. It is then ready for use. 

Egg- Flip. — Beat half an ounce of powdered sugar and the yolks of two 
eggs together, adding eight tablespoonfuls of brandy and eight table- 
spoonfuls of cinnamon and water previously mixed together. 

Liebig's Quick Beef -Tea. — Ingredient. — Half a pound of gravy-beef. 

Time required, about a quarter of an hour. 

Cut up half a pound of gravy-beef very fine, removing all the skin and fat, 
and place it in a saucepan with half a pint of water. Put the saucepan on 
the fire, and let it boil quickly. After it has boiled for five minutes, then 
pour it off into a cup, and it is ready for use. 

Beef- Tea. —Ingredient. —One pound of gravy-beef. 

Time required, about six hours. 

One pound of gravy-beef should be placed on a board, and minced up very 
finely, all the skin and fat being removed. The meat should then be put 
into a saucepan with one pound and a half of cold water, half a saltspoonful 
of salt, and a little pepper. When just boiling, remove the saucepan to the 
side of the fire and let it simmer gently for five or six hours with the lid on. 
Next pour off the beef-tea, and let it get cold. 

It is well to remove all fat from the beef- tea before warming it up for use. 
But it is better not to strain beef-tea, as this removes all the little brown 
particles which are most nutritious. 



APPENDIX. 241 

Fluid Beef. — Take 1 lb. of "newly-killed beef, chop it fine ; add four 
wineglassfuls of soft or distilled water, four or six drops of pure hydrochloria 
acid, a saltspoonful of salt, and stir it well together. 

After three hours throw the whole on a conical hair-sieve, and let the fluid 
pass without pressure. 

Pour a wineglassful of soft or distilled water slowly on the flesh residue in 
the sieve, and let it run through while squeezing the meat. The resulting 
fluid has a red colour and a pleasant taste of soup. A wineglassful may be 
taken at pleasure. It must not be warmed more than by partly filling a 
bottle with it, and placing the bottle in hot water. A little spice or 
"Worcester sauce, or a wineglassful of claret, may be added to each teacup ful 
of soup to disguise the flavour. The acid may be omitted if not desirable. 
Fowl may be used instead of beef. (Dr Broadbent).* 

Infusion of Raw Meat. — This is made from meat chopped up finely, and left 
to soak in half its weight of water for two hours ; then it is pressed through 
a cloth so that the juice remains in the water. Infusions of raw meat should 
not be kept longer than twelve hours, and then only in ice or in a cold cellar, 
as they are apt to get bad. If made from raw meat an infusion has the 
colour of blood ana is, therefore, disagreeable to most patients. Yeal 
infusion is not so nourishing as that made from beef or mutton ; chicken 
infusion is least nourishing, but most appetising. Meat infusions should 
never be cooked, but may be flavoured with a slice of lemon or a little claret 
when taken cold. They may also be added to ordinary beef- tea or Liebig's 
extract of a moderate degree of heat ; a few teaspoonfuls of the infusion aie 
enough at a time. 

Chicken Broth. — Skin and chop up half an old fowl or chicken, then 
place it in a 3tewpan with a quart of water, adding a sprig of parsley, a bit 
of mace, with a crust of bread, salt, and pepper. 

"When sufficiently boiled, take off the broth, strain it, and skim it when 
cool. 

Thin Mutton Broth. — Take off the fat and skin from two chops from the 
neck or loin of mutton. When chopped into thin bits, boil them for half an 
hour, in three-quarters of a pint of water, with a little thyme and parsley. 
Let the broth boil quickly, skimming off all the fat. 

Two tablespoonfuls of powdered biscuit may be added to each pint, and 
boiled with the broth for five minutes, stirring briskly if the broth is not 
sufficiently nutritious. 

Mutton Broth.— To make 2 quarts of mutton broth, take 4 lbs. of 
the scrag end of the neck of mutton, and chop it into large pieces on a board, 
taking away the fat. Place it in a Btewpan with two knuckle bones of 
mutton, and pour 5 pints of cold water over it, adding a saltspoonful of 
salt. When it is just boiling, put it aside, and let it simmer gently for four 
hours. Watch it, and skim it frequently. Drain the stock into a basin, let 
it cool and form into a stiff jelly. Remove all fat from the surface of the 
stock, then take a cloth dipped in hot water, and dab it upon the stock so as 
to take off every particle of grease. After this the 6tock should be wiped 
quite dry, and it is ready for use. 

Veal Broth. — Mince up 1 lb. of lean veal without bone, and putting 
it into a quart of cold water with a little salt, simmer beside the fire for 
three hours, 

m * N. B.~ Valentine's M Meat Juice "may be used a-s a substitute for " Fluid Beef," and, 
like it, should only be warmed by placing the vessel containing it in hot water for a few 
minutes,- 



242 APPENDIX. 

The broth is rendered more nutritious by the addition of two tablespoon- 
fuls of pearl barley, rice, or tapioca, which should be soaked for twelve hours, 
then boiled till soft, and added when the broth is heated for use. A small 
piece of onion may be added when desired. 

Meat Panada. — Grate an ounce of stale bread-crumbs, and after having 
soaked them in boiling water, mix them with about three-quarters of a pint 
of chicken or veal broth or beef- tea, it should then be boiled until it thickens, 
when it is ready for use. 

Meat Jelly. — Put one small carrot and one small onion to fry in a little 
butter with a slice of bacon in a saucepan (a small piece of celery may be 
added). Let it all fry together for about 10 minutes, taking care it does not 
burn. Take 2 lbs. either of veal or shin of beef, or a chicken : cut it up and 
put into the same saucepan with the fried vegetables with 2 pints of cold 
water and a teaspoonful of salt ; let it simmer till it is reduced to about j pint. 
This will take about 6 hours. Then strain off through a fine strainer, and 
when cold take off the fat. It will then be ready for use. 

If preferred, the meat can be put in an earthenware jar in the oven instead 
of in the saucepan. 

Raw Meat Pulp is made by rubbing meat through a sieve, when it may be 
made into sandwiches flavoured with cod-roe or a very small quantity of 
anchovy paste. 

Raw meat pulp may also be prepared with a knife, and the scrapings made 
into sandwiches. 

Peptonised Milk (Roberts). — Mix three-quarters of a pint of fresh milk 
with a quarter of a pint of water, and warm in a saucepan to the temperature 
of about 40° Fahr., then pour into a jug or basin; add two teaspoonfuls of 
Liquor Pancreaticus and half a level teaspoonful of bicarbonate of soda, stir, 
and place near the fire to keep warm. In a few minutes a considerable 
change will have taken place in the milk, but in most cases it is best to 
allow the digestive process to go on for from ten to twenty minutes. A few 
trials will indicate the amount of peptonisation acceptable to the individual 
patient; and as soon as this is reached the milk must be boiled up to prevent 
further peptoDisation, if it is not required by the patient at once.* But, if 
possible, it is better to use the milk without the final boiling, as the half 
finished process of digestion will go on for a time in the stomach. 

Peptonised Beef -Tea. — Half a pound of finely minced lean beef is mixed 
with a pint of water. This is allowed to simmer for an hour and a half. 
When it has cooled down to a lukewarm temperature (about 140° Fahr.) a 
tablespoonful of the Liquor Pancreaticus is added, and it is then kept warm 
for two hours, and occasionally stirred. At the end of this time it is boiled 
for five minutes, and the liquid portion, measuring about half a pint, is 
strained off. Beef-tea prepared in this way is rich in peptone, highly 
nutritious, and of very agreeable flavour. 

The Liquor Pancreaticus or Peptonising Powders are prepared by Benger, 
and may be obtained from any chemist. Full directions are given with these 
preparations for pancreatising and peptonising most forms of foods. 

* The addition of a little coffee to the milk covers the slightly bitter taste caused 
by the Liquor Pancreaticus. 



APPENDIX. 243 

Tea. — Tea may be made with boiling milk instead of water, allowing it to 
stand from three to four minutes. (Sir Andrew Clark's recipe.) 

Eevalenta Arabica. — Mix a teaspoonful of the Revalenta in a dessert- 
spoonful of cold milk until it is quite smooth. Have a breakfast-cupful of 
boiling milk ; stir in the mixture and add a little salt. Continue stirring 
from half an hour to an hour until all rawness has gone. Serve like white 
soup. 

Chicken Cream. — Take half the breast of a chicken, cut it up very fine, 
then pound it in a mortar. Put a small tea-cupful of milk into a little 
saucepan and heat it, then add the pounded chicken by degrees, stirring all 
the time until it is of the consistency of thick soup. Put in a pinch of salt 
and pepper and one or two tablespoonfuls of cream to taste. Serve hot. 
This may be made with veal, mutton, or beef, but the meat must be always 
thoroughly pounded first and any fat removed. 

Caramel Custard. — Put 2 ounces loaf-sugar and two tablespoonfuls of cold 
water into a small saucepan and let it stand on the fire till it becomes brown, 
taking care it does not burn. Take a flat-bottomed mould, or several small 
pots, heat them, and pour enough caramel into each to cover the bottom of 
the mould. Beat up three eggs as you would for an omelet and mix them with 
half a pint of boiling milk, a pinch of salt and 2 ounces castor-sugar, strain it 
and pour into the mould or moulds. Let it stand until quite cold, then turn 
out into a dish. 

Potato Soup. — Take 1 lb. of potatoes, peel and slice them, and add to 
them one small onion, two leaves of celery which have sweated for five 
minutes in 1 ounce of butter. Pour over the vegetables 1 pint of white 
stock (other stock will do), and stir frequently with a wooden spoon ; let it 
boil gently till the potatoes are reduced to a pulp. Put half a pint of milk 
into a stewpan and heat it. Pass the contents of the first stewpan through 
a fine sieve with a wooden spoon, adding by degrees the half pint of hot 
milk which will enable it to pass through more easily. Wash out the first 
stewpan, and pour in the puree. Add salt to taste and a quarter of a pint of 
cream ; stir smoothly with a wooden spoon until it boils, then serve. 



244 APPENDIX, 



APPENDIX B. 

Ice Poultice. — Take a fold of gutta-percha tissue a little larger than the 
area to be covered. Sprinkle on the lower leaf of the tissue a thin layer of 
linseed-meal, and upon it place ice crushed small to the depth of half an 
inch, sprinkle the ice with common salt, and on the top of it add another 
layer of linseed-meal. Turn the upper leaf over the lower and seal the edges 
with chloroform or turpentine ; put the poultice into a flannel bag, and 
place under it a layer of lint. {Guys Plmrmacopceia), 



INDEX. 



A. 

Abdomen, 29. 
Abscess, 158. 
Addison's disease, 95. 
Adipose tissue, 24. 
Ague, 133. 

management of, 134. 

symptoms of, 134. 

Air-passages, 50. 
Air-sacs, 51. 
Albumen, 29. 

test for, 103. 

Albuminuria, 103. 
Alimentary canal, 80. 

diseases of, 84. 

Amputations, 184. 
Amyloids, 83, 84. 
Anatomy, 14. 
Aneurysm, 78. 
Angina pectoris, 77. 

management of, 78. 

symptoms of, 77. 

Antiseptic dressings, 225. 

gauze, 226. 

method, 225. 

rules for nurses, 196. 

solutions, 200. 

treatment, 224. 

Aorta, 71. 

aneurysm of, 79. 

valvular disease of, 77. 

Aphasia, 36. 
Apoplexy, 36. 
Arachnoid fluid, 32. 
Artery, 71. 

axillary, 71. 

brachial, 71. 

carotid, 71. 

femoral, 71. 

popliteal, 71. 

pulmonary, 69. 

radial, 71. 

subclavian, 71. 

ulnar, 71. 

Artificial respiration, 232. 
Ascites, 75. 
Aspiration, 61. 
Aspirator, 61. 
Asthma, 56. 

management of, 57. 

symptoms of, 57. 

Auricles, 68. 

B. 

Bandage, capeline, 229. 

figure-of-8, 227. 

for breast, 228. 



Bandage for eye, 229. 

for finger, 230. 

for groin, 228. 

for head, 229. 

for knee-joint, 227. 

for leg, 230. 

for stump, 230. 

four-tailed, 169. 

many-tailed, 191, 230 

plaster of Paris, 174. 

reverse, 227. 

roller, 226. 

spica, 228. 

spiral, 227. 

T-bandage, 187, 230. 

Baths, cold, 205. 

continuous, 204. 

foot, 206. 

graduated, 205. 

hip, 205. 

hot-air, 206. 

hot and warm, 204. 

mercurial, 207. 

vapour, 207. 

Batteries, faradic, 235. 

galvanic, 235. 

Bed and bedding, 4. 

changing sheets, 6. 

water-, 5. 

Bed-pans, 7. 
Bed-rest, 10. 
Bed-sores, 6. 

prevention of, 38. 

Bile, 82, 83. 

duct, 82. 

Binder, application of, 
Bladder, 100. 
Blood, 27. 

clotting of, 29. 

corpuscles of, 29. 

poisoning, 161. 

serum of, 29. 

Blood-vessels, 14. 
Bowels, 82. 

obstruction of, 90, 144. 

perforation of, 90. 

ulceration of, 146, 118. 

Brain, 32. 

compression of, 168. 

concussion of, 168. 

membranes of, 32. 

tumours of, 42. 

Bright's disease, 102. 

acute, 102. 

chronic, 103. 

diet in, 103, 104. 

management of, 103, 104. 

symptoms of, 102, 103. 



246 



INDEX. 



Bronchitis, 65. 

kettle, 223. 

management of, 56. 

symptoms of, 55. 

Bronchus, 51. 

inflammation of, 55. 

Burns, 163. 

management of, 163. 



C. 

Caecum, 82. 

inflammation of, 

Callus, 166. 
Capillaries, 27. 
Carbolic solution, 200. 
Carpus, 21. 
Catarrh, 54. 
Catheter, 185. 

fever, 185. 

passing, 185. 

washing, 186. 

Cellulitis, 159. 
Cerebellum, 33. 
Cerebrum, 32. 
Chart, diabetic, 106. 

typhoid, 119, 121, 125. 

Chest, 19. 

Chicken-pock, management of, 114. 

symptoms of, 114. 

Childbed, 193. 

management of, 195, 197, 200. 

Children, artificial feeding of, 137. 

diseases of, 139. 

feeding of, 137. 

observation of, 135. 

Chloasma, 100. 
Choking, 81. 
Cholera, Asiatic, 128. 

English, 90. 

infantile, 145. 

instruction of Local Government 

Board, 130. 

management of, 128. 

precautions to be observed by nurse, 

129. 

symptoms of, 128. 

Chorea, 45. 

management of, 46. 

symptoms of, 45. 

Chyle, 84. 

Circulation, capillary, 27. 

portal, 71. 

pulmonary, 73. 

systemic, 71. 

Circulatory system, 25, 71 
Clavicle, 20. 
Cleft palate, 180, 
Clotting, 29. 
Cold, a, 54. 
Colic, 88. 

gall-stone, 88. 

management of, 88. 

renal, 104. 

Collar-bone, 20. 
Colon, 82. 
Coma, 36, 168. 
Compression of brain, 168. 
Concussion of brain, 168. 
Condy's fluid, 200. 
Connective tissue, 14. 
Constipation, 143. 



Constitutional disturbance, 158. 
Contagion, 111. 
Convulsions, 43. 138, 139. 

brain, 43. 

epileptic, 44. 

hysterical, 47. 

Cooking for invalids, see Appendix. 

Corns, 94. ' 

Corpus callosum, 32. 

Corpuscles, 29. 

Cough, 53, 65. 

Counter-irritation, 216. 

Cradle for fracture, 173. 

Cranium bones of, 16. 

Croup, 55. 

false, 141. 

Crutches, 174. 
Cupping, wet and dry, 218. 
Cuticle, 93. 
Cutis, 93. 



Delirium, 48. 

active, 48. 

busy, 48. 

management of, 48. 

quiet, 48. 

Delirium tremens, 48. 
Desquamation, 116. 
Diabetes, 105. 

chart of, 106. 

dietary, 107. 

management of, 107. 

symptoms of, 105. 

urine in, 105. 

Diaphragm, 19. 
Diarrhoea, 91, 144. 

diet in, 92, 145. 

management of, 92, 145. 

motions, 91. 

summer, 91, 145. 

Diet, 83. 

diabetic, 107, 108. 

Digestion, 83. 
Digestive organs, 80. 

system, 25, 80. 

Digitalis, over-dose of, 77. 
Diphtheria, 126. 

management of, 126. 

paralysis from, 127. 

symptoms of, 126. 

Disinfection, 112. 

rules for, 112, 113. 

Dislocations, 176. 
Douche, cold and hot, 211. 

nasal, 212. 

vaginal, 211. 

Draw-sheet, 7. 
Dropsy, 74. 

management of, 74. 

Duodenum, 82. 
Dyspepsia, 84. 

management of, 85. 

Dyspnoea, 54, 74. 

E. 

Ear-syringing, 220. 
Eczema, 95. 

management of, 96. 

Electricity, application of, 235. 
Electrodes, 235. 



IXDEX. 



247 



Empyema, 61. 

management of, 62. 

Emulsion, 83. 
Enema, 208* 

medicated, 210. 

nutrient, 211. 

oil, 210. 

simple, 210. 

Enteric fever (see Typhoid fever), 118. 
Epiglottis, 81. 
Epilepsy, 43. 

management of, 44. 

symptoms of, 43. 

Epithelium, 93. 
Erysipelas, 159. 

management of, 160. 

Erythema, 94. 
Excreta, 8. 
Excretion, 30. 
Excretory system, 26. 
Expiration, 53. 
Eye-drops, 219. 
lotions, 220. 

F. 

Face, bones of, 17. 

Faeces, 92. 

Fats, 24, 83. 

Feeding-cups, 8. 

Femur, 21. 

Fever, continued, 110. 

hectic, 64, 110. 

■ infectious, 110, 114. 

intermittent, 110. 

kinds of, 110. 

■ non-infectious, 132. 

remittent, 110. 

typhoid, 118. 

typhus, 118. 

Fibula, 22. 
Fistula, 188. 
Flatulence, 85. 
Fomentations, 215. 

laudanum, 216. 

poppy, 216. 

turpentine, 216. 

Fontanelle, 18. 

Food, administrations of, 11. 

Foods, 83. 

Foot, bones of, 22. 

Fracture, apparatus, 171. 

Colles', 171. 

■ comminuted, 166. 

compound, 165, 175. 

first aid in, 167. 

kinds of, 165. 

of collar-bone, 170. 

of humerus, 170. 

of leg, 173. 

of lower jaw, 169. 

of patella, 174. 

of pelvis, 170. 

of ribs, 170. 

of skull, 168. 

of spine, 169. 

of thigh bone, 171. 

of ulna and ] 

setting, 166. 

■ • signs of, 166. 

simple, 165. 

union of, 166. 

ununited, 166. 



G. 

Gall-bladder, 82. 
Gangrene, management of, 

moist and dry, 183. 

Gastric catarrh, 142. 

juice, 81. 

ulcer, 87. 

management of, 

symptoms of 87 

Gastritis, 87, 142. 
Germs, 110, 224. 
Gullet, 81. 

H. 

Haematemesis, 86. 

management of, 86. 

Hematuria, 102. 
Haemoptysis, 66. 

management of, 66. 

Haemorrhage, after operation, 179. 

kinds of, 154. 

methods of arresting, 155. 

reactionary, 179. 

recurrent, 180. 

Hair, 93. 

Hand, bones of, 21. 
Hare-lip, 180. 
Heart, 68. 

chambers of, 68. 

dilatation of, 78. 

disease of, 75. 

fatty disease of, 78. 

malformation of, 78. 

movements of, 73. 

valves of, 68. 

valvular disease of, 76. 

Hernia, 188. 

forms of, 189. 

reducible, 189. 

strangulated, 189, 190. 

truss for, 189. 

Herpes, 97. 
Hot-water bottles, 9. 
Humerus, 20. 
Hydrocephalus, 150. 
Hysteria, 46. 

management of, 47. 

symptoms of, 46. 

I. 

Ice, application of, 213. 

Ice-bag, 213. 

Ice-cap, 213. 

Ice poultice, see Appendix B. 

Incubation period, 114. 

Indigestion, 84. 

management of, 85. 

Infantile paralysis, 40. 

management of, 40. 

Infants, artificial feeding of, 137. 

constipation in, 143. 

convulsions in, 138. 

diarrhoea in, 144. 

disorders of, 136. 

feeding, 137. 

management of new-born, 200. 

observations of, 135. 

■ teething in, 138. 

wasting in, 137. 

Infection, 111. 

prevention of, 111. 



248 



INDEX. 



Inflammation, 158. 
Influenza, 131. 

management of, 132. 

symptoms of, 131. 

Inhalations, 221. 

fuming, 222. 

Inhaler, 221. 

Injections, hypodermic, 234. 
Insanity, 49. 
Inspiration, 53. 
Intermittent fever, 133. 
Intestinal colic, 88. 

management of, 90. 

obstruction, 90. 

symptoms of, 90. 

Intestines, 82. 
Invasion period, 114. 
Isolation, 111. 
Itch, the, 98. 

J. 

Jaundice, 86. 

management of, 87. 

Joints, 22. 

— - stiffness after fracture, 171. 



Kidneys, 26, 100. 
— diseases of, 102. 

inflammation of, 102. 

(See Bright's disease.) 



Labour, management of, 194, 197. 

stages of, 194. 

Lactation, 198. 
Lacteals, 26, 84. 
Laryngismus, 141. 

management of, 141. 

Laryngitis, 55. 

management of, 55. 

symptoms of, 55. 

tubercular, 67. 

Larynx, 50. 

inflammation of, 55. 

Leech-bites, 218. 
Leeches, 217. 
Lice, 98. 
Ligaments, 23. 
Limbs, 20. 
Lithotomy, 186. 
Lithotrity, 186. 
Liver, 26, 82. 
Lochia, 197. 
Lockjaw, 162. 
Locomotor ataxy, 40. 

management of, 41. 

symptoms of, 40. 

Lunacy, 49. 
Lunatic asylum, 49. 
Lungs, 50. 

inflammation of, 57. 

Lying-in room, 193. 
Lymphatic glands, 26. 

system, 84. 

Lymphatics, inflamed, 160. 



Malaria, 133. 
Massage, 237. 



M. 



Measles, 117. 

management of, 117. 

Medicines, administration of, 12 

measured glass for, 9. 

Medulla oblongata, 33. 
Melsena, 91. 
Meningitis, 41. 

management of, 42, 149. 

symptoms of, 41, 149. 

tubercular, 148. 

Metacarpus, 21. 
Mouth, 80. 
Mumps, 127. 

management of, 127. 

symptoms of, 127. 

Muscles, 14, 23. 
Mustard leaves, 216. 
poultice, 215. 

N. 

Naevus, 97. 
Nails, 93. 
Navel, 202. 
Nerves, 14. 
Nervous system, 24. 
Nettle-rash, 95. 
Neuritis, 39. 

management of, 39. 

symptoms of, 39. 

Nits, 98. 
Nostrils, 81. 
Nurse's dress, 4. 
Nutrition, 30. 

O. 

(Edema, 74. 
(Esophagus, 81. 
Ointments, 219. 

Operation, arrangement of room in private 
houses, 13. 

haemorrhage after, 179. 

management of patient after, 179. 

preparation of patient for, 177. 

room, 178. 

table, 178. 

Osmosis, 30. 
Ovariotomy, 190. 

complications, 191. 

management of, 191. 



Pads, 231. 

Pains after labour, 198. 

false, 194. 

labour, 194. 

Palate, 80. 
Pancreas, 26, 82. 
Papillae, 93. 
Paralysis, 35. 

brain, 36. 

diphtheritic, 127. 

nerve, 39. 

spinal, 37. 

Paraplegia, 37, 169. 

management of, 38. 

symptoms of, 37. 

Parasites, 98, 99. 
Parotid gland, 26, 81. 
Patella, 21. 



IKDEX 



249 



Patient, attendance on, 6. 

daily report of, 11. 

lifting, 7. 

observation of, 10. 

washing, 6. 

Pediculi, 98. 

management of, 98. 

Pelvis, 19. 
Pepsin, 82, 83. 
Peptones, 83. 
Pericarditis, 75. 

management of, 76. 

symptoms of, 76. 

Pericardium, 68. 

inflammation of, 75. 

Perinaeum, lacerations of, 199. 
Periosteum, 16. 
Peristalsis, 83. 
Peritoneum, 83. 

inflammation of, 88. 

Peritonitis, 88. 

management of, 89. 

symptoms of, 89. 

Perspiration, 66. 
Petechia?, 95. 
Petit mal, 44. 
Peyer's glands, 83. 
Phalanges, 21. 
Pharynx, 81. 
Phosphates, 101. 
Phthisis, 62. 
Pigmentation, 95. 
Piles, 188. 
Pleura, 50. 

inflammation of, 59. 

Pleurisy, 59. 

management of, 60. 

symptoms of, 60. 

with effusion, 60. 

Pneumonia, 57. 

management of, 59. 

symptoms of, 57. 

varieties of, 58. 

Pneumo-thorax, 67. 
Poultices, bread, 215. 

charcoal, 215. 

jacket, 214. 

linseed, 214. 

mustard, 215. 

yeast, 215. 

Poultice Ice, see Appendix B. 
Proteids, 29, 83. 
Psoriasis, 95. 
Ptyalin, 84. 
Puerperal fever, 199. 

prevention of, 200. 

Pulmonary consumption, G2. 

acute, 63. 

chronic, 63. 

complications of, 66. 

management of, 65. 

symptoms of, 63. 

Pulse, 73. 
Pus, 158. 
Pylorus, 81. 
Pyaemia, 161. 

management of, 161. 

symptoms of, 161. 



Quinsy, 142. 



Radius, 26. 
.Rectal cases, 187. 
Reflex action, 35. 
Renal colic, 104. 

management of, 105. 

Respiration, 50. 

artificial, 232. 

mechanism of, 52. 

Respiratory act, 53. 
Respiratory system, 25. 

diseases of, 54. 

Respiratory tract-, 50. 
Rheumatic fever, 132. 

complications of, 138. 

hyper-pyrexia in, 133. 

management of, 132. 

symptoms of, 132. 

Ribs, 19. 
Rickets, 139. 

management of, 140. 

symptoms of, 139. 

Ring-worm, 99. 

management of, 99. 

Rubbing, 237. 



Sacrum, 19. 
Salivary glands, 81. 
Sand-bags, 231. 
Scabies, 98. 

management of, 98. 

Scalds, 163. 
Scapula, 20. 
Scarlatina, 114. 
Scarlet fever, 114. 

management of, 115. 

symptoms of, 114. 

Scybala, 91. i 

Sebaceous glands, 93. 
Sensation, loss of, 35. 
Shingles, 97. 
Sick-room, 1. 

arrangement of, 4. 

cleanliness, 6. 

furniture of, 4. 

temperature of, 2. 

ventilation of, 2. 

Skeleton, 16. 

Skin, diseases of, 94. 

structure of, 93. 

Skull, 17. 

Slings, 231. 

Small-pox, management of, 116. 

symptoms of, 116. 

Snuffles, 203. 
Sore throat, 142. 

management of, 142. 

Sphincter, 82. 
Spinal column, 18. 

cord, 33. 

nerves, 34. 

Spleen, 26. 
Splints, 170, 174. 
Spongio-piline, 216. 
Sprains, 175. 
Spray-producer, 221. 
Starch, 84. 
Sternum, 20. 



250 



INDEX. 



Stimulants, administration of, 12. 
Stirrup for extension, 172. 
Stomach, 81. 

perforation of, 87. 

ulcer of, 87. 

Stone in bladder, 186. 
Stools, examination of, 92. 
Stupes, 215. 
St Vitus's dance, 45. 
Sugar, digestion of, 84. 

in urine, 105. 

Suppositories, 219. 
Sutures, 17. 
Sweaty feet, 109. 
Sympathetic system, 25. 
Syringe, ball, 210. 

enema, 208. 

hypodermic, 234. 



Tape worm, 148. 
Tarsus, 22. 
Teeth, 80, 138. 
Teething, 138. 
Temperature of body, 1, 233. 

of sick-room, 2. 

Tendons, 14, 23. 
Tepid-sponging, 208. 
Tetanus, 162. 

management of, 162. 

symptoms of, 162. 

Thermometer, clinical, 233. 

Thigh-bone, 21. 

Thoracic duct, 84. 

Thorax, 19. 

Thread worms, 147. 

Throat application, 220. 

Thrush, 141. 

Tibia, 22. 

Tinea, tonsurans, 99. 

Tongue, 80. 

Tonsils, 81. 

enlargement of, 142. 

Tourniquet, 156. 

artificial, 156, 157. 

Trachea, 51. 

Tracheotomy, management of, 181. 

tubes, 182. 

Trepanning, 169. 
Truss for hernia, 189. 
Tube en chemise, 187. 
Tube, rectal, 210. 
Tubercle, 62. 
Tubercular meningitis, 148. 

management of, 149. 

■ symptoms of, 149. 

Typhoid fever, 118, 146. 

complication of, 120. 

constipation in, 123. 

convalescence, 124. 

diet and feeding, 122, 147. 

management of, 120, 122, 146. 

motions in, 123. 

■ relapse in, 120. 

symptoms of, 119, 146. 



Typhus fever, 118. 

management of, 118. 

U. 

Ulcers, 162. 

Ulna, 20. 

Urates, 101. 

Ureters, 100. 

Urethra, 27. 

Urine, examination of, 101, 103, 105 

retention of, 184. 

suppression of, 102. 

Urticaria, 95. 
Uvula, 80. 



Vaginal examinations, 195. 
Valves of heart, 69. 
Veins, 28. 
Varicella, 114. 
Variola, 116. 
Veins, 28. 

hepatic, 73. 

inferior vena cava, 71. 

portal, 73. 

pulmonary, 73. 

superior vena cava, 1. 

valves of, 28. 

Ventilation, 2, 53. 
Ventricles, 68. 
Vermiform appendix, 82. 

inflammation of, 89. 

Vertebras, 18. 
Vesico-vaginal fistula, 187. 
Vomit, 85. 

of blood, 86. 

Vomiting, 85. 

management of, 85. 

W. 

Warts, 94. 
Water-beds, 5. 
Water-brash, 85. 
Wet-pack, cold, 207. 

half, 208. 

hot, 207. 

Whitlow, 160. 
Whooping-cough, 54. 
Wind-pipe, 51. 
Work and waste, 27. 
Worms, intestinal, 147. 

management of, 147, 148. 

Wounds, complications of, 154, 159. 

contused and lacerated, 151. 

dressing of, 152. 

healing of, 151, 152. 

incised, 151. 

■ inflamed, 158. 

■ of face, 154. 

of scalp, 153. 

of throat, 154. 

of trunk, 154. 

poisoned, 160. 



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tion. 321110. Cloth, .40 

"This small volume is written as a supplement to the author's well-known 
work on nursing. It treats only of the conditions of pregnancy and labor. It 
is clear in its statements, and will prove of great value to those whose duty it 
is to care for women during and after confinement." — N. Y. Medical Journal. 

DOMVILLE. Manual for Nurses and Others 
Engaged in Attending to the Sick. By Ed. J. Dom- 
ville, m.d. Seventh Edition. With Directions for 
Bandaging, Preparing and Administering Enemata, 
Fomentations, Poultices, Baths, etc., Recipes for 
Sick-room Cookery, Tables of Weights, and a Com- 
plete Glossary of Medical Terms. Cloth, .75 



BOOKS ON NURSING. 



CANFIELD. The Hygiene of the Sick-Room. 

A Book for Nurses and Others, being a Brief Consid- 
eration of Asepsis, Disinfection, Bacteriology, Im- 
munity, Heating and Ventilation, and Kindred Sub- 
jects, for the use of Nurses and Other Intelligent 
Women. By Wm. Buckingham Canfield, a.m., 
m.d., Lecturer on Clinical Medicine, and Chief of 
Chest Clinic, University of Maryland, Visiting Phy- 
sician to Bay View Hospital, etc. i2mo. 247 pages. 
Handsome Cloth Binding, J 1.25 

*%* This book is the outcome of a series of lectures delivered by 
Dr. Canfield at the University of Man-land Training School for 
Nurses. It contains much valuable information not included in the 
regular text-books, but which of necessity the nurse should be ac- 
quainted with. 

" We recommend it to the attention, not only of sick-nurses, but also all other 
persons, of either sex, who desire a knowledge of the behavior of disease, as it 
concerns infection ; and the manner in which foulness, either of wounded sur- 
faces, or of the sick-room, or of the dwelling-house, may be prevented. 

"Each disease is taken up in turn (typhoid fever, consumption, diphtheria, 
etc.) and the methods of management of the discharges, etc , are described in 
detail. The formulae for the preparation of disinfecting solutions, for clothing, 
utensils, privies, etc., are clearly set forth; such details as one may search his 
library in vain for are here given in a compact form. 

" The prevention of blindness in infants receives full attention. Ventilation 
is duly considered, and a chapter is given to the thoughtful discussion of immu- 
nity and protection from disease. The book closes with some remarks upon 
the diet of the sick-room. We congratulate Dr. Canfield on his work. It is 
well worth the moderate price." — Maryland Medical Journal. 

GRAPHIC CLINICAL CHART. Designed by 

J. P. Crozer Griffith, m.d. The purpose of this 
chart is to give, in the most concise form, a complete 
record of pulse, respiration, and temperature of the 
patient. Its simplicity and the ease with which it is 
kept commend it to nurses, and the clearness of the 
design makes plain at a glance the full history of the 
case. Price, in packets of 50, .50 



ANATOMY A ND P HYSIOLOGY. 

POTTER'S Anatomy. Fifth Edition. 117 
Illustrations and 16 Lithograph Plates. A 

Compend of Human Anatomy. By Saml. O. L. 
Potter, m.a., m.d., m.r.c.p. (Lond.), Professor of 
the Practice of Medicine, Cooper Medical College, 
San Francisco. i2mo. Cloth, .80 

" This is, in its way, a wonderful little book, comprising within its pages £. 
more or less complete account of every part of the human body, not even omit- 
ting the histology of the tissues and organs." — Edinburgh Medical Journal. 

*' Contains many useful hints and aids to memory not found in ordinary 
works." — Canada Lancet. 

" The arrangement is well calculated to facilitate accurate memorizing, and 
the illustrations are clear and good." — North Carolina Medical Journal. 

BRUBAKER'S Physiology. Seventh Edition, 
Enlarged and Improved. Illustrated. A Com- 
pend of Physiology, including Embryology. By 
A. P. Brubaker, m.d., Demonstrator of Physiology 
at Jefferson Medical College ; Professor of Physiology, 
Pennsylvania College of Dental Surgery, Philadelphia. 
28 Illustrations. i2mo. Cloth, .80 

" This is an admirable compend of physiology, including enough of anatomy 
to fit it especially for the use of students of medicine. It has been prepared by 
one who is fully fitted by his work as Demonstrator in the Jefferson Medical 
College, and as Professor of Physiology in the Pennsylvania College of Dental 
Surgery, and by his experience as quiz-master, to compile such a book, and it 
has proved its utility by the acceptance it has already found. Its style is 
clear and distinct, its teachings are sound, and it is well suited to the 
purpose for which it is intended." — Medical and Surgical Reporter. 



MATERIA MEDICA AND THERAPEUTICS, 



POTTER'S Materia Medica, Therapeutics, 
and Prescription Writing. Sixth Edition. 

Compend of Materia Medica, Therapeutics, and Pre- 
scription Writing. With special reference to the Phy- 
siological Action of Drugs. By Samuel O. L. Potter, 
m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon, 
U. S. Army ; Professor of the Practice of Medicine, 
Cooper Medical College, San Francisco. i2ino. 

Cloth, .80 



BOOKS FOR NURSES. 



HORWITZ'S Surgery. Minor Surgery and 
Bandaging. Fifth Edition. 167 Illustrations. 

A Compend of Surgery, including Minor Surgery, 
Amputations, Fractures, Dislocations, Surgical Dis- 
eases, Antiseptic Rules, Formulae, etc., with Differen- 
tial Diagnosis and Treatment, and a Complete Section 
on Bandaging. By Orville Horwitz, b.s., m.d., 
Professor of Genito-Urinary Diseases ; late Demonstra- 
tor of Surgery, Jefferson Medical College, etc. Fifth 
Edition. 324 pages. 121110. Cloth, .80 

*g* The new Section on Bandaging and Surgical Dress- 
ings consists of 34 Pages and 40 Illustrations. Every 
Bandage of any importance is Figured. 

WYTHE'S Dose and Symptom Book. The 

Physician's Pocket Dose and Symptom Book. Con- 
taining the Doses and Uses of all the Principal 
Articles of the Materia Medica, and Officinal Prepa- 
rations. By Joseph Wythe, a.m., m.d. Seventeenth 
Edition; revised and rewritten, containing Tables of 
Weights and Measures, Rules for Proportioning the 
Doses of Medicines, Hints on Treatment, etc. 
Cloth, .75; Leather, with Tucks and Pocket, §1.00 

WESTLAND. The Wife and Mother. A 

Medical Guide to the Care of her Health and the 
Management of her Children. By Albert West- 
laxd > m.d. 121110. Illustrated. Cloth, $1.50 

From the Philadelphia Medical News. 

"A noticeable point about this little volume is the commendable absence of 
technical terms, as the author plainly states that it is for the use of ' women who 
are desirous of fulfilling their proper duties of wives and mothers.' Too often, 
in works of this class, the readers for whom they are intended are confused and 
led astray by the multiplicity of words and phrases meant rather for the prac- 
titioner than the mother. . . . Altogether the books fulfills the objects for 
which it was written, and will materially assist the young married woman in 
the intelligent performance of new duties." 

From the Nurse, Boston. 

" The style is easy and fascinating. It should be in the hands of every nurse 
and married women." 



NEW EDITION. 

ACCIDENTS and EMERGENCIES. 

A Manual for the treatment of Surgical and other Injuries, 
Poisoning and various Domestic Emergencies, in the absence of the 
Physician. 



By CHARLES W. DULLES, M.D., 

Surgeon to the Out-Door Depart))ient of the University and Presbyterian 
Hospitals , Philadelphia. 



Fourth Edition, Enlarged. New Illustrations. 12mo. • • 

ILLUSTRATED. 

SHORT LIST OF CONTENTS. 



Cloth, $1.00 



Preliminary Remarks. 
Obstructions to Respiration. 
Foreign Bodies in the Eye, Nose and 

Ear. 
Fits or Seizures. 
Injuries to the Brain. 
Effects of Heat. 
Effects of Cold. 
Sprains. 
Dislocations. 
Fractures. 
Wounds of all kinds, including the 

bites of Dogs, Cats, Snakes, Insects, 

etc. 
Railroad and Machinery Accidents. 



Hemorrhage — Bleeding. 

Special Hemorrhages. 

Transportation of the Injured. 

Poisons and their Antidotes. 

Domestic Emergencies, includes Chol- 
era Morbus, Vomiting, Diarrhoea, 
Nervous Attacks, Earache, Tooth- 
ache, Asthmatic Attacks, Croup, 
etc., etc. 

Signs of Death. 

Supplies for Emergencies. 

The Surgical and Medicine Case, 
their contents and use, Bandaging, 
Poultices, etc. 

Index. 



*** This book should be in the possession of every head of a 
family, Nurse, Manufacturer, Police Lieutenant, Sea Captain, Hos- 
pital Steward, School Teacher, Druggist, etc. etc. 

" Several attempts have been made to prepare a volume which would serve 
as a handy manual for reference in the time of need, in the absence of a doctor, 
but none have succeeded better than the present little work. It should be in the 
hands of all officers charged with the public conveyance of passengers, to be 
read, in preparation for emergencies, and afterward to serve as a book of refer- 
ence." —North Carolina Medical Journal. 

" This little manual contains simple directions for the preliminary treatment 
of accidents to all parts of the body and of such diseases as persons are suddenly 
Seized with. Without profuseness or an unintelligible vocabulary, it contains in 
a small space a deal of useful information." — New York World. 

u This is a revised and enlarged edition, with new illustrations, of the manual, 
explaining the treatment of surgical and other injuries in the absence of the phy- 
sician. The simple and practical suggestions of this little book should be known 
to every one. Accidents are constantly occurring, and a knowledge of what 
should be done in an emergency is very valuable. Such a handbook should be 
in every home, placed where it can always Le found readily. — Boston Journal 
of Education. 



" I may say that Dr. E. P. Davis' Manual has proved useful to me 
in teaching obstetrics by its clearness and its many practical sugges- 
tions."— MARION E. SMITH, Chief Nurse Philadelphia Hospital. 

DAVIS. Manual of Practical Obstetrics. By 
Edward P. Davis, a.m., m.™.. Clinical Lecturer en Obstet- 
rics in the Jefferson Medical College, Professor of Obstetrics 
and Diseases of Children in the Philadelphia Polyclinic, 
Visiting Obstetrician to the Philadelphia Hospital. Second 
Edition, Enlarged. 351 pages; 150 illustrations, several 
of which are colored. Cloth, 32.00 

" I have carefully reviewed the ' Manual of Obstetrics' by Dr. E. P. Davis. 

" It is full, accurate, concise, and gracefully and clearly written. It is a most 
excellent Manual of the art it teaches." — Prof. J. Snyda/u Knox, Rush 
Medical College, 2227 Calumet Avenue, Chicago. 

" I have read it with interest, and consider it one of the best works on the sub- 
ject for the use of students and practitioners. " — Dr. James P. Boyd, Albany 
Medical College, Albany, N. Y. 

41 I am so well pleased with the work that I have recommended it to my class. " 
— Dr. A . L. Breysacher, Medical Department A . I. U , Little Rock, A rk. 

" I have completed my examination of it, and want to say that I think it is 
the biggest little work on the subject it has been my privilege to look over. It 
is surely a complete work, devoid of theory, replete with practice. I heartily 
commend it as a manual. " — Dr. J. R. Rathmell , Chattanooga Medical College, 
Tenn. 

" I would say that in style and character it is abreast with the most modern 
and approved methods and thought upon the subject, that for brevity it is clear, 
systematic, and concise, very suitable for the busy student during the session at 
college, and for the busy practitioner as well. It gives the essentials, and I shall 
take pleasure in recommending it to my students. " — Dr. M. R. Mitchell, Kan- 
sas Medical College •, Topeka, Kan. 

" It is especially clear and pleasing in style and the subject matter is well 
chosen. It is a good text-book. " — Dr. Clara Marshall, Philadelphia. 

" It is concise and accurate, and I cordially recommend it as admirablv suited 
to the convenience of the medical student and busy practitioner. " — Dr. De 
Laskie Miller , Rush Medical College, Chicago, III. 

" I consider it a very good book. " — Prof. A P. A. King, National Medical 
College, Columbian University, Washington, D. C. * 

" I consider it a valuable work, especially for the recent graduates who are 
entering upon the practice of obstetrics and pursuing post-graduate studies. 

" I keep my copy where I can read it, and consult its pages almost daily, and 
generally find what I want in a few lines." — Dr. P. C. Clayberg, American 
Medical College, St. Louis, Mo. 

" The book appears to me to meet the purposes for which it is written and to 
be a valuable addition to the library of the busy practitioner. " — Prof. Randolph 
Winslow, University of Maryland, Baltimore, Aid. 

" I am well pleased with the 'Manual of Obstetrics' by Dr. E. P. Davis, 
and can recommend the work to the profession." — Prof. C. A. Pauly, Pulte 
Medical College, Cincinnati O. 

M The book is a most excellent one. After careful investigation, I have no 
hesitation in cordially recommending it to anybody in need of a small manual." 
—Dr. M. D. Mann, Buffalo, N. Y. • 



THE 



American Health Primers. 

EDITED BY W. W. KEEN, M.D., 

Professor of Surgery in the Jefferson Medical College, Fellow of the College 
of Physicians of Philadelphia, etc. 



12 Vols. 32mo. Attractive Cloth Binding, each 40 Cents. 

This Series of Health Primers is prepared to diffuse as widely and 
cheaply as possible, among all classes, a knowledge of the elementary facts of 
Preventive Medicine. They are intended incidentally to assist in curing dis- 
eases, and to teach people how to form correct habits of living, and take care 
of themselves, their children, employees, etc. 

I. HEARING AND HOW TO KEEP IT. With Illustrations. By Chas. 

H. Burnett, m.d., of Philadelphia, Aurist to the Presbyterian Hospital. 

II. LONG LIFE AND HOW TO REACH IT. By J. G. Richardson, m d , 
of Philadelphia, late Professor of Hygiene in the University of Pennsyl- 
vania. 

III. THE SUMMER AND ITS DISEASES. By James C. Wilson, m.d , 
of Philadelphia, Professor of the Practice of ftledicine, Jefferson Medical 
College. 

IV. EYESIGHT AND HOW TO CARE FOR IT. With Illustrations. By 
George C. Harlan, m d., of Philadelphia, Surgeon to the Wills (Eye) 
Hospital. 

V. THE THROAT AND THE VOICE. With Illustrations. By J. Solis 
Cohen, m.d., of Philadelphia, Lecturer on Diseases of the Throat in Jef- 
ferson Medical College, aivl on the Voice in the National School of Oratory. 

VI. THE WINTER AND ITS DANGERS. By Hamilton Osgood, m.d., 
of Boston, Editorial Staff Boston Medical and Surgical Journal. 

VII. THE MOUTH AND THE TEETH. With Illustrations By J. W. 
White, m.d., d.d.s., of Philadelphia, Editor of the Dental Cosmos. 

VIII. BRAIN WORK AND OVERWORK. By H. C. Wood, Jr., m .d ., of 
Philadelphia, Clinical Professor of Nervous Diseases in the University of 
Pennsylvania. 

IX. OUR HOMES. With Illustrations. By Henry Hartshorne, m.d , 
of Philadelphia, formerly Professor of Hygiene in the University of Penn- 
sylvania. 

X. THE SKIN IN HEALTH AND DISEASE. With Illustrations. By 
L. D. Bulkley, m.d., of New York, Physician to the Skin Department 
of the New York Hospital. 

XI. SEA AIR AND SEA BATHING. With Illustrations. By John H. 
Packard, m.d., of Philadelphia, Surgeon to the Pennsylvania Hospital. 

XII. SCHOOL AND INDUSTRIAL HYGIENE. By D. F. Lincoln, m.d., 
of Boston, Mass., Chairman Department of Health, American Social 
Science Association. 

" The series of 'American Health Primers ' deserves hearty commendation. 
These handbooks of practical suggestions are prepared by men whose profes- 
sional competence is beyond question, and, for the most part, by those who 
have made the subject treated the study of their lives." — New York Sun. 

*** Each Volume 50 Cents, in Attractive Cloth Binding. 



BYFORD'S 
MANUAL OF GYNECOLOGY 

Two Hundred and Thirty-four Illustrations. 

By Henry T. Byford, m.d., Professor of Gynecology 
and Clinical Gynecology in the College of Physicians 
and Surgeons of Chicago ; Professor of Clinical Gyne- 
cology in Woman's Medical School of Northwestern 
Universitv, etc. 



12mo. 488 Pages. Cloth, $2.50, 



Though prepared more especially for medical stu- 
dents and young physicians, this book has many 
points that recommend it to the nurse who wants 
to thoroughly understand the important details of 
gynecological nursing. 

The chapters in Part One on gynecological tech- 
nique and the principles of gynecological treat- 
ment are more minute in detail than is usual in 
such books, special attention being given to the 
duties of the nurse, to aseptic and antiseptic mat- 
ters, instruments, etc., etc. A series of eight illus- 
trations showing the various postures in which the 
patient is placed for examination or operating will 
prove exceedingly useful. 



GOULD'S POCKET MEDICAL LEXICON. 



12,000 MEDICAL WORDS 

PRONOUNCED AND DEFINED. 

A Pronouncing Lexicon of Medical Words Specially Adapted for 
Nurses, Including Many Useful Tables and a Dose List. 

BY GEORGE M. GOULD, M.D., 

Author of " An Illustrated Dictionary of Medicine, Biology, and Allied 
Sciences ," " The Student's Medical Dictionary," etc. 

Pocket Size. 317 Pages. Gilt Edges, Full Morocco. 
Price $1.00; with a Thumb Index, $1.25. 



OVER 47,000 COPIES OF GOULD'S DICTIONARIES 
HAVE BEEN SOLD. 



" Gould's Dictionary, Pocket Edition, is the most complete and convenient I 
have seen." — Mario?i E. Smith, Head Nurse, Philadelphia Hospital, Phila. 

" The Pocket Dictionary is a little gem." — L. J. Gross, Head Nurse, Buffalo 
General Hospital. 

41 1 have examined Gould's Dictionary, and consider it the best dictionary in 
a small compass that I have seen. The price, too, is most reasonable I shall 
recommend it to all our nurses." — F. Hutcheson, Head Nurse, Flower Mission 
Training School for Nurses, Indianapolis, Ind. 

" 1 shall certainly have the nurses each send for a copy of the dictionary. It 
is just what they need, and is a nice size to carry." — Harriet Sutherland, Head 
Nurse t Margaret Pillsbury Hospital, Concord, N H. 



4Gtf* Every nurse should have a copy of this little book in order 
to intelligently pursue her studies and to thoroughly understand 
the physician's directions. It furnishes a vast amount of informa 
tion not to be obtained in the regular text-books. 






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PRINTED IN U.S.A. L 




H Humphry. 
237.143 A manual of nursing, 
H83 medical and surgical.